What is Fatty Liver?
Fatty Liver is defined as the condition in which fat starts accumulating in the liver cells or hepatocytes. This can lead to liver inflammation where the liver swells up in size compared to its normal size. The liver is an organ that helps to detoxify the blood by breaking down toxins, drugs, alcohol, and caffeine. It produces bile to digest food, processes the nutrients from food, regulates blood sugar by storing glucose in the form of glycogen and releasing it back into the blood when blood sugar goes low, produces cholesterol and specialized proteins, processes hemoglobin, regulates blood clotting, and many more functions.
Our lifestyles have changed drastically, with poor dietary habits and lack of exercise and movement. Due to this, there is a drastic increase in non-communicable diseases such as diabetes, heart diseases, hormonal disorders, and obesity. Fatty liver has now come under the radar as it is one of the most concerning medical conditions affecting people worldwide.
Key Takeaways
- Fatty liver is a reversible medical condition when detected early.
- To reverse fatty liver, lifestyle modifications such as diet, exercise, and weight loss, along with treatment of metabolic conditions, can help to manage fatty liver.
- Regular monitoring is crucial to prevent progression of the disease.
Types of Fatty Liver
ALD (Alcoholic Liver Disease)
Where alcoholism or heavy drinking can cause liver failure and death.
NAFLD (Non-Alcoholic Fatty Liver Disease)
Used for those who do not consume alcohol. It was also known as NASH or Non-Alcoholic Steatohepatitis.
In recent times, a new term for fatty liver which is called MAFLD or Metabolic Dysfunction Associated Fatty Liver Disease was coined by scientists in 2020 to indicate this new lifestyle problem. The main difference between NAFLD and MAFLD is that NAFLD will be diagnosed in those patients who have ≥ 5% fat infiltration in the liver without alcohol consumption and other diseases such as Viral hepatitis, while MAFLD also shares the same criteria but is caused due to contributing effects of at least two of the following metabolic disorders.
Criteria for diagnosis of MAFLD:
- Pre-diabetes and Type 2 Diabetes Mellitus
- Increased waist circumference
- High blood pressure
- High triglycerides
- Insulin resistance score
- High C-reactive protein
- Low HDL or High Density Lipoprotein levels
Acute Fatty Liver of Pregnancy (AFLP)
This happens mostly during the third trimester of pregnancy where the fat accumulates in the liver during pregnancy and can be dangerous to both the mother and child and may result in premature delivery. It is extremely rare and can be genetic. This condition may return to normal after a few weeks of delivery. If not diagnosed early, it can cause complications such as liver failure, kidney failure, lung failure, and hemorrhage.
Toxicant-Associated Fatty Liver Disease (TAFLD)
Exposure to various toxic substances which could be medicinal, environmental, or occupational can cause TAFLD.
It may be caused by:
- Drugs such as Tamoxifen, Methotrexate, Amiodarone
- Inhaling passive cigarette smoke
- PAHs (Polycyclic Aromatic Hydrocarbons) - produced during burning of coal, grilled meats, tobacco, gasoline
- Air pollution - PAHs mixed with Particulate Matter, Nitrogen oxides
- Asbestos - found in cement, pipes, roofing, and other construction material
- Aflatoxins - fungal toxins found on maize, corn, peanuts, rice
- Pesticides
- Heavy metal exposure - arsenic, cadmium, lead, mercury, nickel, chromium
- Organic solvents - trichloroethylene (TCE) used in cleaning metal parts
- Perfluorooctanoic acid (PFOA) in Teflon coating - used in cooking utensils
- Radiation exposure
- Trihalomethanes (THMs) - found in drinking water which has been chlorinated
- Methyl tertiary-butyl ether (MTBE) - found in gasoline
- Selenium - used in manufacturing of glass and electronics
Exposure to most of these chemicals has been associated with TAFLD, and more research is needed to understand the cellular changes occurring in TAFLD cases.
What are the factors that cause Fatty Liver?
Dietary causes for Fatty Liver
Diet plays a major role in the cause for fatty liver. The main function of the liver is that it manages the breakdown of fat and calories we eat from our food. It also produces cholesterol. But a high-calorie diet with high fat and carbohydrate intake can trigger fatty liver.
Foods that increase the risk for fatty liver:
- Excessive intake of unhealthy fats from biscuits, cookies, puffs, cakes, chips, and baked products
- Margarine or Vanaspathi
- Excessive intake of fats and oils, particularly trans fats
- High sugar intake, particularly foods containing High Fructose Corn Syrup (HFCS)
- Excessive intake of refined foods such as refined wheat flour or maida, white rice, and other refined cereals
- Fried foods
- Red meats such as mutton, pork, beef
- Processed meats such as bacon, sausages, ham, burger patties, etc.
- Milk products such as processed cheese, high-fat cottage cheese, or paneer
- High-fat gravies made of cream and coconut
- Low fiber intake
- Low intake of Polyunsaturated Fatty Acids, particularly omega-3 fatty acids
Weight factors for Fatty Liver
Weight gain resulting from eating too many calories can cause fat to build up in the liver cells. Constant overeating can exhaust the liver and stop the processing of fat. This can lead to accumulation of excessive fat in the liver, causing liver damage.
According to the Asian BMI, overweight individuals have a Body Mass Index between 23-24.9 kg/m², and obese individuals have a BMI above 25 kg/m². According to WHO, the adult BMI for overweight individuals is between 25-29.9 kg/m², and obese individuals have a BMI above 30 kg/m². Increase in BMI can increase the risk for fatty liver.
Rapid weight loss or malnourishment may also trigger fatty liver due to rapid breakdown of fats (lipolysis) and increased release of free fatty acids from adipose to fat tissues. However, the mechanism has not been fully understood by researchers, while there are several studies supporting the fact that Very Low Calorie Diets (VLCD) may help in reversing fatty liver. Hence, we can conclude that results may vary between individuals. It is best to progress with gradual weight loss under the supervision of a doctor and a dietitian.
Waist Circumference
Being overweight or obese can increase your waist circumference. If the waist circumference is more than 35 inches for females and 39 inches for males, this can be a big risk for fatty liver. In one study, when a large group of people underwent scanning with various imaging techniques, it was found that most of those who had high amounts of visceral or belly fat also had fatty liver conditions.
Metabolic Conditions
Various metabolic conditions may cause fatty liver as a secondary condition. The following metabolic conditions for fatty liver are:
- High blood pressure
- High cholesterol levels
- High triglyceride levels
- Insulin resistance, pre-diabetes, Type 2 Diabetes Mellitus
- PCOD and PCOS
- Hypothyroidism (low levels of thyroid hormones)
- Hypogonadism (low levels of sex hormones)
- Hypopituitarism (low levels of pituitary hormones, particularly growth hormones)
- Obstructive Sleep Apnea (snoring)
- Wilson's disease - genetic condition leading to accumulation of copper
- Hemochromatosis - genetic condition leading to overabsorption of iron
Non-Modifiable Risks
- Gender - Males are more prone to fatty liver than females.
- Age - Males under the age of 50 have a higher risk, and after 50, the risk reduces. Women under the age of 50 have a lower risk, but the risk increases in women post-menopause.
- Genetics - may depend on environmental exposure
- Ethnicity - Asians and Hispanics have a higher risk when compared to other ethnicities.
Constant exposure to pollution, environmental, and work-related exposure to toxins can lead to fatty liver condition.
Stages of Fatty Liver
There are four stages of Fatty Liver:
Stage 1: Fatty Liver
Initial stage where the fat has started to accumulate in the liver. There is no significant damage to the liver and can easily be reversed.
Stage 2: Non-Alcoholic Steatohepatitis (NASH)
Over time, the liver gets inflamed or swollen, and progressive damage is seen. This stage is still reversible.
Stage 3: Fibrosis
There is significant scarring of liver tissue. The liver tissue becomes stiff. This stage is mostly irreversible, but if treated early, one can prevent the progression of the disease.
Stage 4: Cirrhosis
The healthy liver is completely covered by scar tissue, affecting the functioning of the liver. If left untreated, it is fatal as it can lead to liver failure and cancer. Liver transplantation may be the only option.
Therefore, it is important to prevent it and treat it in the early stages.
Symptoms of Fatty Liver
Fatty liver may show no symptoms in the initial stages. There may be a few warning signs such as pain in the upper right side of the abdomen and tiredness.
The severity of the symptoms usually appears in Stage 4, where one will experience yellowing of eyes and skin (jaundice), loss of appetite, weight loss, weakness, itchy skin, nausea, dark-colored urine, pale stools due to jaundice, fluid buildup in the abdomen (ascites), swollen feet, mental confusion, GI bleeding, and spider veins on the skin.
Diagnosis of Fatty Liver
If you are already overweight or obese with unhealthy eating habits or have any of the mentioned metabolic conditions and symptoms, then it is crucial to undergo a medical examination.
- Physical examination - A physician can perform a palpation on the abdomen to detect any swelling.
- Blood tests - Liver function tests can be done to check for fatty liver. Elevated levels of liver enzyme tests such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST) can help in the diagnosis.
- Scanning - Ultrasound exams, CT, and MRI scans can help to detect fat deposition in the liver and diagnose the fatty liver stages.
- Biopsy - Liver biopsy, which involves extraction of the liver tissue, can help in diagnosis.
Treatment of Fatty Liver
The treatment for fatty liver will depend on the causative factors and medical conditions.
Lifestyle Modifications
Diet
- Eat healthy fats such as nuts and seeds such as walnuts, almonds, flax seeds, sesame seeds
- Safe cooking oils include coconut oil, mustard oil, groundnut, and sesame oil. Use moderately and avoid deep frying. Avoid refined oils such as sunflower, rice bran, and corn oil
- Plant-based diets with a lot of vegetables, green leafy vegetables and fruits, whole grains, and pulses
- Low-fat milk products are advised
- Avoid red meat and eat lean meats such as fish and chicken
- Strictly avoid sugar
- Reduce sodium intake
- Avoid foods rich in trans fats
- Read food labels to make the right choices
- Caffeine intake has been investigated as a preventive measure against fatty liver, but will need further research
Weight Loss
- Reduce high-calorie intake and get your energy requirements customized by a dietitian. Calorie reduction and weight loss can help in reducing insulin resistance as well as help in reversing fatty liver.
- Regular exercise can help in weight loss. Exercising 3-5 times per week along with a weight loss diet can significantly help to reverse the condition.
Intervention for Metabolic Conditions
- Managing diabetes through regular monitoring, medications, diet, and exercise
- Reducing cholesterol and triglyceride levels
- Reduce exposure to pollution and toxins
Pharmacological Interventions
Studies have shown treatment with Vitamin E, Omega-3 supplements, Pioglitazone, GLP-1 agonists have shown some promise, but have not been approved by FDA for the management of NAFLD.
Bariatric surgeries in morbidly obese cases used for weight loss can help to reverse fatty liver.
Prevalence of Fatty Liver across the world
It is said that nearly 25% of adults worldwide are living with fatty liver disease. It is highest in the Middle Eastern and South American countries, and in Asia, India is catching up. It has been reported that one in every three adults now have fatty liver. Even children are affected by this medical condition. It is said that 38.6% of adults and 35.4% of children in India have fatty liver. It is higher in the urban population with 40%, while the rural population is about 29.2%.
Frequently asked Questions
Can fatty liver be cured?
Yes if diagnosed in the early stages it can be successfully reversed. The more advanced the stage, the more difficult it is to resolve. So if you have the risk factors such as being overweight with poor eating habits, it is better to get tested to detect it as early as possible. Fatty liver is a silent disease and does not have any symptoms.
Are fatty liver and liver cirrhosis the same?
No, liver cirrhosis is an advanced stage of liver disease while the initial stage of liver disease is fatty liver. Liver cirrhosis is not reversible but can be managed by medical intervention, while fatty liver can be reversed with diet and lifestyle changes. Untreated fatty liver condition can progress into liver cirrhosis which is life threatening.
How long does it take to cure fatty liver?
This will vary between individuals depending on the stage, age, existing medical issues and life styles. It may take weeks to months to resolve with the right interventions of diet and lifestyle changes.
I occasionally consume small amounts of alcohol. Will I still get fatty liver?
Yes, you can still develop fatty liver depending on your eating habits along with the alcohol intake. No amount of alcohol is safe for the liver.
My weight is normal, yet I have been diagnosed with fatty liver. What could be the reason?
Although weight is a major factor for fatty liver, there are many other causative factors such as smoking, alcohol intake, dietary habits such as high sugar intake, visceral fat, insulin resistance, gut imbalances, low estrogen levels in women, genetics, malnutrition which can predispose even a person with normal weight to get fatty liver.
