Fatty liver is a silent killer diagnosed through ultrasound or echocardiogram. Diagnosis of fatty liver symptoms can enable timely fatty liver treatment.

Non-Alcoholic Fatty Liver Disease (NAFLD) In Pakistan

Introduction

Fatty liver disease is very common throughout the world. The condition is characterized by the storage and accumulation of extra fat in the liver. Mostly, there are no serious symptoms nor does it interfere with daily life activities. However, leaving the condition unattended may eventually cause liver damage.&nbsp;

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One particular type of fatty liver, called non-alcoholic fatty liver disease (NAFLD) has seen a global rise in cases and associated mortality. In the United States, NAFLD is a leading cause of chronic liver disease<a href="#accordion">[1]</a>. Moreover, it continues to be a leading cause of end-stage liver disease worldwide<a href="#accordion">[2]</a>. A population-based observational study revealed a global increase in cases from 391.2 million in 1990 to 882.1 million in 2017<a href="#accordion">[2]</a>. The highest case numbers were seen in East Asia, South Asia, North Africa, and the Middle East<a href="#accordion">[2]</a>.

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Obesity, unhealthy diet, lack of physical activity, and diabetes are some of the most established risk factors for non-alcoholic fatty liver disease (NAFLD)<a href="#accordion">[2]</a>. However, in recent years, the medical literature has reported an increase in cases among people without any of the mentioned risk factors. Called lean NAFLD, the fatty liver disease is seen to be affecting non-obese or lean individuals with a normal body mass index (BMI). As per a recent meta-analysis, approximately 40% of the global NAFLD population was found to be non-obese and a fifth were lean<a href="#accordion">[3]</a>.&nbsp; 
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Understanding Non Alcoholic Fatty Liver Disease In Pakistan

To fully understand how any condition affects your body, it is crucial to understand its functioning first.&nbsp;

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The liver is an essential organ and has crucial functions that involve the production of bile to aid in digestion, storage of iron for your blood, creation of immune factors as well as the removal of toxic substances from the body as it processes the nutrients obtained from food.&nbsp;

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Liver is also responsible for aiding your blood with substances that help it clot whenever there is an injury; clotting stops the body from losing any more blood.&nbsp;

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All of these functions get affected one way or another if your liver is not working fully. Every function associated with the liver is one way or another related to your body&rsquo;s immune system and basic functioning<a href="#accordion">[4]</a>.&nbsp; &nbsp; &nbsp;&nbsp; 
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Like the name suggests, it is simply extra fat in your liver. However, it can be of 2 main types:

&nbsp;

<ul>
	<li>Alcohol-induced fatty liver disease - As the name suggests, the disease is brought on due to heavy alcohol consumption.&nbsp;</li>
	<li>Nonalcoholic fatty liver disease (NAFLD) - The condition presents in the absence of alcohol consumption. With a global prevalence of 25%, it is a common cause of chronic liver disease worldwide<a href="#accordion">[5]</a>. Although the exact cause remains unclear, it has been linked to obesity, diabetes, and an unhealthy lifestyle. It can be further divided into:</li>
</ul>

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1. Simple Fatty Liver: This refers to fat in your liver without inflammation or damaged liver cells. This fatty liver does not cause noticeable issues and tends to go unnoticed. Most cases of fatty liver are like this.&nbsp;

2. Non-Alcoholic Steatohepatitis (NASH): This is a much more serious condition than just the conventional fatty liver. NASH involves inflammation and liver cell damage along with fat accumulation. NASH has been associated with causing fibrosis and cirrhosis. It makes up about 20% of the total cases of non-alcoholic fatty liver diseases<a href="#accordion">[6]</a>. 
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Despite the high prevalence of the issue in Pakistan, research suggests that people in high income countries are affected the most for e.g. In the US, the prevalence of fatty liver disease ranges from 10-46%. The higher rate is due to the obesity epidemic in the US<a href="#accordion">[7]</a>.&nbsp; &nbsp;

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In Pakistan, <a href="https://merisehat.pk/disease/obesity">obesity </a>does exist and while it may not be as hard of a hit as it is in the United States, it is still worrisome and does not get due attention. The rise in obesity coupled with poor health awareness and lifestyle choices, have led to a drastic increase in fatty liver issues in Pakistan as well. As per research, around 15% of Pakistan&rsquo;s population now suffers from nonalcoholic fatty liver disease<a href="#accordion">[8]</a>. However, it is important that NAFLD in Pakistan is seen in not only obese patients but also patients suffering from diabetes and dyslipidemia. Furthermore, a 2017 study conducted among a Pakistani cohort identified male gender and advanced age as major risk factors for metabolic disturbances linked to NAFLD<a href="#accordion">[9]</a>.

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Between 2013 and 2014, researchers in Peshawar, Pakistan analyzed the prevalence of NAFLD and NASH in hospitalized and ambulatory patients at Combined Military Hospital Peshawar Cantonment area. The overall prevalence of NAFLD was 47%, with Pathans demonstrating the highest numbers<a href="#accordion">[10]</a>. Moreover, NAFLD was more common among male patients, diabetics, hypertensive and older individuals<a href="#accordion">[10]</a>.

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Most patients with fatty liver have dyslipidemia even if they do not suffer from other contributing factors. The ever-increasing rate of nonalcoholic fatty liver disease in Pakistan requires multiple population-based studies to be carried out to determine the root cause, and the cultural and lifestyle impact on the disease and its development<a href="#accordion">[8]</a>. 
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Non-alcoholic fatty liver disease does not really have a lot of discomforting symptoms. You may experience tiredness or abdominal pain towards the upper right side.&nbsp;

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However, in the case of non-alcoholic steatohepatitis or cirrhosis, you may experience the following symptoms:

<ul>
	<li>Irritated palms</li>
	<li>Jaundice &ndash; yellowing of eyes and skin</li>
	<li>Swollen belly</li>
	<li>Enlarged blood vessels&nbsp;</li>
	<li>Bigger breasts in men 
	&nbsp;</li>
</ul>

This is probably the hardest part of the disease. There are no visibly discomforting symptoms that would make you see the doctor. However, it is also common to get to know about the condition while diagnosing some other issues.&nbsp;

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The diagnosis starts off with taking a health history. This is carried out through a series of questions that involve asking about your diet, medications, and any health conditions. It is followed by blood tests to assess if you have increased levels of liver enzymes (aminotransferase, alanine, or aspartate aminotransferase). Incidental abnormal liver enzymes commonly lead to a NAFLD diagnosis. However, in 80% of cases, the liver enzymes are in the normal range<a href="#accordion">[8]</a>. Therefore, proper screening programs with abdominal imaging are required for the diagnosis of NAFLD. Especially, in individuals with risk factors such as obesity, diabetes, and hypertension. Moreover, even non-obese or lean individuals should be kept in mind when screening for NAFLD.&nbsp;

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The most common method used for diagnosis is through ultrasounds and, in most cases, that is also how people get to know about the issue<a href="#accordion">[11]</a>.&nbsp; &nbsp; &nbsp; 
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There is no targeted medicine for the treatment of fatty liver disease. The best approach for maintenance is to monitor and maintain other contributing factors that revolve around lifestyle changes. The earlier you adopt these changes, the better:

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<ul>
	<li>No smoking</li>
	<li>No alcohol consumption</li>
	<li>Maintaining optimum weight&nbsp;</li>
	<li>Controlling other health issues, like diabetes, cholesterol, etc.</li>
	<li>Taking vitamin E 
	&nbsp;</li>
</ul>

Conclusion

The statistics in Pakistan are not as bad as other countries like the US; nevertheless, the numbers are increasing. Moreover, with the increasing obesity and unhealthy lifestyle trends in the country, the burden of NAFLD is expected to increase further. This poses a growing concern to public health. Therefore, there is a need for increasing awareness among the population and promoting a healthy lifestyle.&nbsp;

Key Points

<ul>
	<li>Fatty liver refers to the accumulation of fat on the liver. The two main types are alcohol-induced fatty liver disease and nonalcoholic fatty liver disease (NAFLD)</li>
	<li>NAFLD can be divided into&nbsp;simple fatty liver disease, which is common, and the less common non-alcoholic steatohepatitis, which is responsible for the formation of cirrhosis and fibrosis in people.</li>
	<li>Contributing factors include obesity, high LDL levels, diabetes, etc.</li>
	<li>There is no treatment, however, it can be maintained and prevented by taking care and maintaining a perfect BMI.</li>
	<li>With the increasing obesity and unhealthy lifestyle trends in the country, the burden of NAFLD is expected to increase further. Therefore, there is a need for increasing awareness among the population and promoting a healthy lifestyle.</li>
</ul>

[1] Kanwal F, Kramer JR, Duan Z, Yu X, White D, El-Serag HB. Trends in the Burden of Nonalcoholic Fatty Liver Disease in a United States Cohort of Veterans. Clin Gastroenterol Hepatol. 2016;14(2):301-8.e82. doi:10.1016/j.cgh.2015.08.010

[2] Ge X, Zheng L, Wang M, Du Y, Jiang J. Prevalence trends in non-alcoholic fatty liver disease at the global, regional and national levels, 1990-2017: a population-based observational study. BMJ Open. 2020;10(8):e036663. Published 2020 Aug 3. doi:10.1136/bmjopen-2019-036663

[3] Ye Q, Zou B, Yeo YH, et al. Global prevalence, incidence, and outcomes of non-obese or lean non-alcoholic fatty liver disease: A systematic review and meta-analysis. The Lancet Gastroenterology & Hepatology. 2020;5(8):739-752. doi:10.1016/s2468-1253(20)30077-7

[4] Fatty liver disease: Risk factors, symptoms, types &amp; prevention. Cleveland Clinic.

[5] Chrysavgis L, Ztriva E, Protopapas A, Tziomalos K, Cholongitas E. Nonalcoholic fatty liver disease in lean subjects: Prognosis, outcomes and management. World J Gastroenterol. 2020;26(42):6514-6528. doi:10.3748/wjg.v26.i42.6514

[6] Fowler P. Fatty liver disease: Nonalcoholic &amp; alcoholic steatohepatitis (NAFLD/AFLD). WebMD.

[7] Fatty liver disease. UCLA Health System.

[8] Abbas Z, Zaheer R. Non-alcoholic fatty liver disease: A real threat in Pakistan. Journal of the Pakistan Medical Association. 2020:1. doi:10.5455/jpma.95891

[9] Ghani RA, Saqlain M, Zafar MM, Jabeen S, Naqvi SM, Raja GK. Identification of Metabolic risk phenotypes predisposing to Non-Alcoholic Fatty Liver Disease in a Pakistani Cohort. Pak J Med Sci. 2017;33(1):121-126. doi:10.12669/pjms.331.11445

[10] Shah AS, Khan S, Rahim H, Chishti KA, Khan AG. Prevalence of non alcoholic fatty liver and Non alcoholic Steatohepatitis in Peshawar Cantonment, Khyber Pakhtunkhwa, Pakistan. Pak J Pharm Sci. 2018;31(1):193-198.

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