“I don’t drink, so my liver should be fine.” It is a line many doctors hear almost every day, and it is an understandable assumption, since liver disease has long been tied to alcohol. But the most common liver condition in India today has little to do with what is in your glass.
We spoke to two liver specialists about how fatty liver develops, why it can affect even people who are slim, why it goes unnoticed, and what can reverse it.
The liver disease that has nothing to do with alcohol
“What’s important to note these days is that the most common liver disease in India has nothing to do with alcohol,” says Dr. Harshavardhan Rao B., HoD - Medical Gastroenterology, MS Ramaiah Memorial Hospital, Bengaluru. “Roughly one in three Indian adults may have it and most of them don’t even know that they have it,” he adds.
Dr. Shailendra Lalwani, Chairman - Liver Transplant, HPB and GI Surgery, Manipal Hospital Dwarka, New Delhi, explains what it is. “One of the key causes of liver disease in people who do not drink is metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as non-alcoholic fatty liver disease (NAFLD). It occurs when excess fat accumulates in the liver in association with metabolic risk factors,” he says.
How fat ends up in the liver
“Usually, it is a product of dietary and lifestyle factors which can lead to increased fat deposition in the body,” Dr. Rao says. “Excessive sugar and refined carbohydrates like white rice, maida, sweets, packaged drinks and juices and of course fast food,” he lists, along with “a sedentary lifestyle, poor sleep and stress which is long term.”
“This can lead to something called insulin resistance. Insulin resistance is a common factor that then leads to not just fatty liver but also diabetes, hypertension and high cholesterol,” Dr. Rao explains.
You don’t have to be overweight
Another surprising thing about Indian patients, Dr. Rao says that you don’t have to be overweight to have fatty liver. “This is something that we call a slim fatty liver,” which can happen in Indians who are not overweight but carry fat around the midriff, he explains. Dr. Lalwani agrees: “Individuals with a healthy body weight may also develop it.”
A silent condition
“Clinically, fatty liver is challenging because it is silent. There is no pain, there is no warning and only a liver blood test can pick it up usually done because of an annual checkup or a comprehensive health checkup or a pre-employment checkup,” Dr. Rao says.
“In some people, fat accumulation can progress to liver inflammation and scarring, known as fibrosis,” Dr. Lalwani says. “Not everyone with fatty liver disease will progress to these stages, but identifying the condition early can help reduce the risk of further damage,” he adds.
As the disease advances, signs can include “persistent tiredness, mild discomfort in the upper right abdomen, unexplained weight loss, yellowing of the skin and eyes, and swelling in the legs or abdomen,” he says.
It can be reversed
Good news is if it is caught early, fatty liver is almost always reversible. “It is mainly achieved through changes in dietary and lifestyle practices rather than medicines,” Dr. Rao says. “Losing 7 to 10 percent of your body weight can reduce the fat and also reverse early fibrosis or damage in most patients, almost more than 90 percent of patients,” he adds.
That means cutting down sugar, cutting down refined carbohydrates, cutting down processed food, increasing the fiber in your diet in the form of vegetables, increasing the proteins in your diet especially vegetable sources of protein like dals, nuts, soya, paneer and so on.
Dr. Rao recommends “walking or exercising for at least 150 minutes per week that is the WHO guideline but I would go on to say that it should be more than 200 in younger individuals, sleeping for 6 to 8 hours and making sure that you are following stress management strategies.”
For advanced cases, Dr. Lalwani says options go further. “For people with severe obesity, bariatric (weight-loss) surgery, such as sleeve gastrectomy or gastric bypass, may be considered,” he says. “In advanced cases where scarring has progressed to cirrhosis and the liver begins to fail, liver transplantation... may be the only option,” he adds.
Who should get checked
“Anyone with risk factors like obesity, large waist, diabetes, hypertension, altered cholesterol and even families to have liver disease needs to be screened regularly for fatty liver,” Dr. Rao says. “Usually a blood test and an ultrasound and in case there are any abnormalities in these tests a fibro scan to measure the liver stiffness,” he explains.
“Not drinking is a good choice but it isn’t a guarantee,” Dr. Rao concludes. “Your liver won’t complain until it’s too late.”
Skipping alcohol is a good choice, but it is not a free pass for your liver. Fatty liver can build up quietly, even in people who look slim and feel fine, and by the time symptoms show up, the damage may already be underway.
It is caught early, it can often be reversed with less sugar, more movement, better sleep and a modest drop in weight. If you have diabetes, a large waist, high cholesterol or a family history of liver disease, ask your doctor about a simple liver check.
