Q. Monsoon often triggers a spike in gastrointestinal infections. What are the most common liver-related complications observed during the season and how can those be prevented?
A. Monsoon results in an increase in subsoil ground water, which can be contaminated by sewage leaks and this contaminated water can be transported to the wells and sometimes to households through the pipe water supply. Hepatitis E virus and hepatitis A virus are endemic in India and are excreted through human excreta. It can contaminate drinking water as well as food processed by such water. These viruses are transmitted to humans orally through contaminated water and food causing acute hepatitis manifesting as jaundice due to liver dysfunction. They can be prevented by drinking boiled and then cooled water or after treatment by due process of chlorination. Avoid eating foods from street vendors and prepared in unhygienic conditions.
Q. As a leading hepatologist, what trends do you notice in liver disease prevalence over the last decade in India, particularly among the younger population?
The prevalence of alcohol induced liver damage and fatty liver disease are rapidly increasing in India. The two problems constitute more than three-fourth of overt clinically damaged liver presenting in various stages of liver dysfunction. More than half of the hospital beds in a gastroenterology unit or even many medical units, comprise of advanced and not infrequently life threatening complications of these two etiology-induced liver damage. Though hepatitis B and hepatitis C associated chronic liver disease is in decreasing trend, it continues to be a problem. These conditions can lead to chronic liver disease like cirrhosis and liver cancer which often compromise quality and quantity of human life. All of them can be prevented by awareness, HBV vaccination, avoiding alcohol consumption and foods which cause obesity (sweets, processed foods, aerated drinks, saturated and trans-fats). Younger people are suffering from these diseases due to increased alcohol consumption, lack of regular physical exercise to reduce cardio-metabolic risk factors like obesity, diabetes, dyslipidaemia and hypertension etc.
Q. NAFLD is now being called the silent epidemic. What factors are contributing to its rapid rise in urban and rural India?
Sedentary lifestyle, consumption of junk foods, rapid rise in prevalence of type-2 diabetes mellitus, along with even moderate alcohol consumption (which often accompanies snacking causing additional unwanted calories consumption) are causing more and more fatty liver disease as well as liver damage in people. It is often due to both fat and alcohol which is medically known as Met-ALD (metabolic dysfunction - met with alcoholic liver disease).
Q. How does NAFLD progress into more serious conditions like non-alcoholic steatohepatitis (NASH), cirrhosis, or even liver cancer and what early warning signs should people watch for?
A. About 70% to 80% of diabetics and about 30% to 50% of overweight and obese people (BMI > 23 to 25 with abdominal obesity) may have increased fat in the liver which can progress to more advance liver damage like NASH, now renamed as MASH - Metabolic dysfunction associated steatohepatitis. It indicates liver inflammation and damage often leading to fibrosis. At least, 10% to 25% of people, depending upon the presence of various other factors like dyslipidaemia, diabetes, and even infrequent alcohol consumption, lack of physical activity and consumption of high-risk foods may progress to serious liver damage in the next 10 years. Such people are also more prone to heart attacks, strokes and cancers.
Q. What are some under-discussed lifestyle factors, beyond alcohol and obesity that are damaging liver health these days?
Prolonged sitting, more time spent on screen watching, less sleep, more consumption of carbohydrates and sweets, fried foods, frequent consumption of painkillers and many unwanted complementary alternative medicines even un-indicated hepatotoxic antibiotics may be associated with liver damage.
Q. How do comorbidities like diabetes and hypertension worsen liver function or disease outcomes?
Diabetes and hypertension are manifestations of metabolic dysfunction of the body due to lifestyle changes and often are associated with fatty liver, cardiac dysfunction, renal complications and many other abnormalities. Their association with pre-existing fatty liver are well known synergistic factors for progression of liver disease.
Q. Given the rise in poly-pharmacy, especially in middle-aged individuals, how concerning is drug-induced liver injury (DILI)?
DILI is another problem compounding the liver disease. Drugs for tuberculosis, anti-cancer drugs, complementary alternative medicines, some antibiotics, painkillers and many other drugs can cause liver damage. Therefore, close monitoring of liver functions is needed during such medications.
Q. Is there a role for routine liver function screening even in asymptomatic individuals, especially among those with sedentary lifestyles or obesity?
Definitely. All risk factors, if present in any individual, without symptoms should be evaluated for liver, cardiac and renal dysfunction. Occurrence of hypertension, increase in uric acid, compromised bone density and presence of polycystic ovaries in females should also be looked into. Even fat infiltration to muscles can be there causing increased fatigue and relative muscle loss. Fat in the liver easily detected by an abdominal ultrasound indicates a generalised metabolic dysfunction of the whole body. The human body and its organs evolutionarily have substantial reserves and therefore metabolic dysfunction associated organ damage can be asymptomatic. Therefore, individuals with risk factors like obesity, diabetes, hypertension and alcohol abuse should be screened for presence of abnormalities in various organs. If diagnosed early, all of these abnormalities are completely reversible.
Q. Is there a connection between immunity, gut health, and liver function that people need to be more aware of, particularly during seasonal changes like the monsoon?
The human body should be assessed holistically. Organ cross talk is a naturally evolved process. Gut microbiome is an important determinant of our immune competence and is a barrier against environmental infection. They can enhance liver damage in fatty liver disease and can get altered in presence of diabetes, alcohol consumption and various other bowel as well as systemic illnesses. Diet (vegetarian and non-vegetarian) can alter gut microbiome affecting human health in susceptible individuals. However, monsoon per se cannot be blamed solely for gut health. Rather, it is diet and types of diet, alcohol, presence of uncontrolled diabetes, frequent consumption of antibiotics, bowel habits etc which can influence gut microbiome.
Q. What is your take on hepatitis A and B vaccination rates in India? Are we doing enough to prevent these preventable liver diseases?
Hepatitis B virus immunisation by vaccination starting at birth is already a part of the universal immunisation programme of the Government of India and is being implemented in all states. However, I think Hepatitis A virus vaccination should be given to all children starting at the age of around two years, because hepatitis A-virus induced acute hepatitis is on the rise in all states and often is causing severe liver disease in children and young adults.
Q. Do you believe India needs a national liver health programme or policy, similar to its initiatives on diabetes and heart disease and why?
Yes. Fatty liver disease prevalence is around 30% to 40% in the Indian population. Alcohol consumption is on the rise. More and more DILI are being documented. Substance use is on the rise. Liver due to its huge reserve remains often asymptomatic despite having damage due to various etiologies. When clinically liver dysfunction becomes overt, often disease is in an advanced stage and may be difficult to get corrected needing liver transplant.
Q. How can primary care physicians and public health workers be better trained or equipped to detect liver-related diseases early?
Awareness, availability of liver function tests, ultrasound screening of liver and regular training of doctors and health professionals about various tests and screening methods are necessary to encourage identification and screening of high risk persons prone to develop liver disease.
Q. As liver diseases do not discriminate between vegetarians or non-vegetarians and alcoholic or non-alcoholic, what would be your liver care tips for the common man?
I think regular exercise, nil alcohol consumption, less consumption of foods with high glycaemic index, control of diabetes and dyslipidaemia, if present, avoidance of un-indicated medication, avoiding red meat consumption, saturated and trans-fat, aerated drinks and processed food will be helpful to all in not only preventing liver disease but also promoting good health in general. Further, since smoking aggravates all diseases and it should be completely avoided.
