Understanding Fatty Liver Disease: Insights from a Leading Surgeon

Global Fatty Liver Disease Day Insights

On the occasion of Global Fatty Liver Disease Day, Dr. Arvinder Soin, a prominent liver transplant surgeon and Chairman of the Medanta Liver Institute, discussed the alarming rise of fatty liver disease as the primary cause of liver failure globally, surpassing both alcohol-related liver issues and viral hepatitis. This increasing prevalence poses significant challenges for liver transplantation. Dr. Soin noted that when patients with severe liver disease seek donations from family members, nearly half of these seemingly healthy potential donors are found to have fatty liver disease, rendering them unsuitable for donation.

Q: Have you observed any significant changes in the presentation of fatty liver disease over the past five years?

Dr. Arvinder Soin: The most notable shift is that fatty liver disease has become the leading cause of liver failure worldwide, now outpacing alcoholic liver disease and viral hepatitis. Today, fatty liver disease is the primary reason for liver transplants, whether due to liver failure, cirrhosis, or liver cancer. Disturbingly, we are witnessing this condition affecting younger individuals. We perform one or two liver transplants daily, often turning to siblings or children as potential donors. Surprisingly, nearly 50% of these young, seemingly healthy individuals have fatty liver disease. While some may be overweight, many appear healthy. The prevalence is alarmingly high. We are currently investigating whether lifestyle changes combined with GLP-1 medications can help reduce fatty liver and make these individuals suitable donors.

Another concerning trend is the emergence of liver cancer in patients who have not yet developed cirrhosis. Traditionally, liver cancer was seen in those with cirrhosis, but now we are observing cases where liver cancer develops in patients with fatty liver and early fibrosis.

It's also crucial to understand that fatty liver is not solely a result of poor diet, excessive sugar intake, diabetes, or high cholesterol. Factors such as sleep deprivation, chronic stress, and low muscle mass in older adults significantly contribute to this condition. Many older adults with sarcopenia, or muscle loss, also have fatty liver disease, which may seem contradictory but is frequently observed.

Q: Why was non-alcoholic fatty liver disease (NAFLD) renamed MASLD?

Dr. Soin: The primary reason for this change is that the term 'non-alcoholic fatty liver disease' did not accurately describe the condition. Fatty liver is a sign of metabolic dysfunction, as the liver plays a central role in metabolism. It is closely linked to various metabolic health issues. Individuals with fatty liver often experience insulin resistance, diabetes, obesity, high blood pressure, and abnormal cholesterol levels. The new term, Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD), better captures the disease's underlying mechanisms. The previous name only indicated what the disease was not, failing to explain what it actually is. This change aims to enhance the scientific accuracy of the diagnosis.

Q: Who should be considered for GLP-1 medications?

Dr. Soin: I want to clarify that I am not promoting GLP-1 drugs as a standalone solution; lifestyle changes are essential. Three main criteria are important: the individual must be committed to lifestyle changes, their BMI should generally be above 28, and they should have associated metabolic issues like diabetes or high triglycerides. These criteria guide the selection of patients for GLP-1 therapy alongside lifestyle modifications. The goal is not only to make them suitable donors but also to enhance their long-term health. We have successfully transplanted patients using donors who underwent this process, and detailed results will be published in scientific literature. The combination of GLP-1 drugs and lifestyle changes can help sustain weight loss, as the drugs alone may not be sufficient.

Q: Many believe GLP-1 drugs are a miracle solution for weight loss. What are your thoughts?

Dr. Soin: That misconception is problematic. If lifestyle changes are the primary driver of weight loss and GLP-1 medications merely enhance that effect, then the approach is correct. Viewing it the other way around is a mistake.

Q: Some argue that developing liver disease without alcohol consumption is akin to having consumed alcohol. What is your response?

Dr. Soin: That argument lacks sense. A harmful substance is harmful, whether it’s alcohol, sugar, or uncontrolled diabetes. As liver specialists, we can usually determine the contribution of alcohol to liver damage through tests and clinical findings. While there can be overlap, we can typically identify the role alcohol has played.

Q: What is your stance on liver detoxes and cleanse supplements?

Dr. Soin: I advise against them. There is no supplement or detox product that can cleanse the liver. The best way to detoxify your liver is to avoid toxins in the first place.

Q: Is fatty liver solely a liver issue?

Dr. Soin: Not at all. The presence of fatty liver should not be the end of the investigation. It is part of a broader metabolic dysfunction that can affect multiple organs. Patients should be evaluated for extra-hepatic manifestations of MASLD, which may include heart disease, diabetes, kidney issues, sleep disorders, or polycystic ovarian syndrome (PCOS) in women. Sarcopenia can also be linked to fatty liver. It’s crucial to assess the entire body and identify associated conditions early.

Q: What early warning signs should individuals be aware of?

Dr. Soin: The first step is recognizing your risk factors. If you are overweight, inactive, not sleeping well, experiencing chronic stress, or have diabetes or abnormal cholesterol levels, you are at risk. For instance, someone with a BMI of 27 should be aware that they may have fatty liver disease. Symptoms like pain in the upper right abdomen can occur, but ideally, we should detect the condition before symptoms arise. Fatty liver can be diagnosed through ultrasound, FibroScan, liver function tests, and blood investigations. If the disease progresses, complications such as abdominal swelling, vomiting blood, confusion, or liver cancer may develop. The aim is to identify and manage fatty liver before it reaches that advanced stage.