Nishi Gupta*, a 28-year-old PhD student in Delhi, is not someone you would call overweight. At 5’ 3”, she weighs 61 kg, an extra two to three kilograms out of her ideal height-weight ratio. She looks like any other healthy girl her age when she walks into a clinic at the Institute of Liver and Biliary Sciences, wearing a pair of denims and orange flower-shaped ear-rings. “I did not even drink alcohol,” she says, recalling her diagnosis from two years ago that indicated she had fatty liver disease — a condition where there is a build-up of fat in the liver.Nishi was diagnosed with the condition two years ago after a routine full-body checkup revealed that her liver enzymes were all over the place. Her SGOT and SGPT levels were between 600 and 700 U/L as compared to the normal levels for the enzymes between 7 and 56 U/L. “While my entire family undergoes a complete health check-up once every six months, the one during which my liver condition was diagnosed, was prompted by severe pain in my abdomen. It had gotten so bad that I would board the metro and immediately look for a seat — I just could not stand even for a few minutes,” she says.The doctors did not know what was leading to the high liver enzyme levels, so she was put through a battery of tests. They finally diagnosed her with non-alcoholic fatty liver disease — or what is now referred to as metabolic dysfunction associated fatty liver disease. Metabolic dysfunction is a condition where a body’s normal chemical processes for converting food into energy are disrupted, leading to an imbalance of essential substances or the dysfunction of organs like the liver or pancreas. In other words, an underlying condition could lead to fatty liver, which needs to be arrested early so that it does not stiffen up the liver, scar it and cause cirrhosis.While most people get fatty liver disease because of alcohol consumption or fat deposition in the abdomen, for Nishi it was her underlying, uncontrolled diabetes.How diabetes can be a trigger“I was diagnosed with diabetes after I fainted one day when I was in class X. There were other signs too. I always had a headache. I would be suddenly craving for sweets — getting up in the middle of the night to have some — and I don’t even like sweets.” As she was young and healthy, doctors assumed that she had Type 1 diabetes, where the body’s immune system damages the cells that produce the sugar-regulating hormone insulin, and put her on insulin therapy. Unlike Type-1 diabetes, Type 2 diabetes leads to the body’s cells becoming resistant to insulin. This is why insulin shots are effective for people with Type 1 diabetes but do not always help those with Type 2 diabetes.Nishi knew something was amiss. “My blood sugar levels remained extremely high despite taking five to six shots of insulin every day; most people take only three. There were times when my levels were so high that the glucometer could not even record it. The doctor and my parents thought that I was skipping the shots. They did not listen to me, they kept asking me to take the insulin shots.” For four years, her HbA1c levels — the average blood glucose levels over a period of three months — remained at an extremely high 12 or 13 per cent. Normally, it stays below 5.7 per cent for non-diabetics.It was only when she broke down in the doctor’s office a few years ago that the doctors decided to check what type of diabetes she had. “The doctor said that there was a change in the guidelines a few years ago. Earlier anyone diagnosed with diabetes at a young age was considered to have Type 1 but that was not the case with me. I had the more common Type 2 diabetes, which is why the insulin was not working.” While she was put on appropriate medicines after these tests, the damage was already done. “The doctors told me that the years of living with high levels of blood sugar had resulted in fat deposition in the liver, leading to inflammation,” she says. Now, with proper medicines for diabetes, diet and exercise, she hopes to reverse the condition.Story continues below this ad“The good thing about fatty liver disease is that in the initial stages it is reversible if the underlying problems are corrected. For Nishi, it was about addressing her uncontrolled diabetes. For many others, it was just losing a few kilos and living a healthier life,” says Dr Anoop Saraya, Nishi’s physician and gastroenterologist at ILBS.How lack of physical activity can queer the pitch…For Dr Thiruchelvam Venugopal, 56, it was sitting throughout the day at his dental clinic and an inability to do strenuous exercise due to a knee injury that led to Grade III obesity, which in turn triggered fatty liver disease. A range of disparate symptoms, such as feeling fatigued and lethargic early in the morning while brushing the teeth, excessive sweating and leg swelling, drove him to get a comprehensive health check-up at Apollo Hospital in Hyderabad. “I was diagnosed with fatty liver disease after this health checkup some seven or eight years ago. As my other parameters were in range, I was just asked to make lifestyle changes,” he says.For years, he tried several diets, including intermittent fasting, along with the type of exercise he could manage with his knee injury. “But, I always seemed to hit a plateau,” he says. After several years of back and forth, he finally decided to undergo a type of weight-loss surgery where the stomach is stapled to make it smaller. He had lost about 12 kg in a couple of months. “While the doctors have to test my parameter again to see the impact on my liver, I already feel energetic. The weight loss has also meant that I am able to do more exercise,” he says.…As can dietIt is the lifestyle which is to be blamed in the case of 39-year-old Ganesh Yadav. He too came to ILBS with a fibroscan report showing high levels of fat deposition in the liver. A driver by profession, he was unable to eat timely meals. “When you are out, you also tend to eat a lot of fried food. Now, I am trying to cut down on it. Although I still eat out, I try to choose rajma chawal over a paratha or samosa,” he says.Story continues below this adDr Saraya recommends that once diagnosed, people have to work on correcting their lifestyle. “Diet and exercise become extremely important. People have to cut down on foods that contain added sugar such as ice creams and cakes and those that are deep fried. Cliched as it may sound, patients must have a balanced diet with more lean proteins like fish, fibres in the form of fruits and vegetables, legumes, wholegrains and complex carbohydrates. They should also plan for a 45-minute exercise every day. And keep the weight off,”he says.Why irregular lifestyle is behind the spiralDr Saraya now sees several cases of non-alcoholic fatty liver in his clinic every day, some of them in younger age groups. “It is a metabolic disease and it is following the same pattern of other metabolic conditions such as diabetes.”More than 84 per cent of the IT sector employees in Hyderabad had increased liver fat accumulation, indicating fatty liver disease, according to a study based on data from 345 people. The study found 76.5 per cent of the IT professionals had high levels of low-density lipoprotein (LDL) or bad cholesterol, 70.7 per cent were obese and 20.9 per cent had higher than normal fasting blood glucose levels.Dr Saraya says that the condition has become so common that if people are tested at random, many would be found to have excessive fat deposition in their liver. Most do not get the diagnosis because in the initial stages, there are usually no symptoms. “It is usually detected when people are undergoing tests for other conditions or undergoing health check-ups. But a diagnosis should not lead to stress. This is because a very small percentage of people with the initial stage of fatty liver disease ever progress to cirrhosis (scarring of the live due to the inflammation caused by the fat deposition),” he explains.Story continues below this adWhat do studies sayA 2018 study in the Canadian Journal of Gastroenterology and Hepatology puts this number at around one per cent. The same study says that around 11 per cent of those diagnosed at a more advanced stage of inflammation due to the fat deposit can progress to have cirrhosis. Obesity, especially fat around the abdomen, insulin resistance, high blood glucose levels, high blood pressure and high cholesterol are all risk factors for fatty liver disease.Recent research has shown promising developments in therapeutic strategies with the US Food and Drug Administration (FDA) approving the first drug for liver fibrosis, resmetirom, in early 2024. The new diabetes and weight control medications like GLP-1 and GIP receptor agonists, such as tirzepatide, have demonstrated the potential to reverse fatty liver.Investigations into the gut-liver axis are also revealing how gut microbiota influences NAFLD, suggesting potential interventions such as faecal microbiota transplantation and improved dietary approaches. Additionally, new research is focused on innovative tests to replace invasive liver biopsies so that detection can be made easy and in the early stages.(*Name changed to protect privacy)