A Toxic Problem

SONAM SHENOY, a techie-turned-homemaker based in Lower Parel, Mumbai, had always frowned upon her 15-year-old son’s incorrigible habits, which included avoiding his evening tennis sessions with friends and gorging on sweets like there is no tomorrow. That was her pre-Covid complaint. It got worse during Covid when the teen began taking classes online, spending endless hours on YouTube, and ordering eatables late at night on food delivery platforms he had learned to use. Four months ago, he was diagnosed with fatty liver during a post-Covid medical check-up. His fasting blood sugar levels, besides cholesterol and triglyceride counts, too, were high. “He had become obese, but we were lucky to have got an early diagnosis,” says the 36-year-old Shenoy, whose younger son is also gaining weight like his older sibling even though both parents are slim and have no such tendencies. Now, their older son has shown improvement since he has changed his lifestyle, Shenoy declares. But the paradox and non-linearity of the disease worry her no end. “How can my son, so young, get a fatty liver?” she asks with wonder and regret.

Doctors the world over are divided about the gravity of the problem at hand. While some of them advise against panic and assert that it is just a marker of our modern lifestyle and that there is no evidence yet that fatty liver in teens can lead to liver cirrhosis some 10-15 years later, many others, especially in India, argue that diagnosis of a fatty liver in a teen or a pre-teen is confirmation of the nation’s poor health—that it is the tip of the iceberg of debilitating and life-threatening diseases that will sink the nation’s overall health in the future.

“Obesity leads to multiple health complications and fatty liver is just one of them,” says Dr Nibin Nahaz, a Kerala-based gastroenterologist who has published several papers, including on paediatric liver injuries. When asked about the so-called hype around fatty liver, Dr Arulraj Ramakrishnan, a UK-trained hepatologist, bluntly declares, “The hype is partly true and partly not. The population of India is sure to make it a disease burden.” He avers that if you change your lifestyle as soon as you are diagnosed with a fatty liver and exercise well, you are unlikely to get a serious health problem.

But we all know that it is easier said than done, considering the lifestyle-related problems in India, the proliferation of cases of obesity, and related health hazards. The statistics from a plethora of research studies covering teens as well as adults, including people from interior India who lead physically demanding lives, are nightmarish—they disclose that there is perhaps more to liver infections than what meets the eye. And this doesn’t include people afflicted with liver injuries due to excessive consumption of alcohol. Of course, alcohol contributes to liver damage and finally death due to cardiac problems and cancer. But more importantly, doctors are increasingly coming across patients with non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). While NAFLD simply means that you have a fatty liver but no damage to your liver, NASH is the condition when you have fat in your liver plus signs of inflammation and liver cell damage, according to Johns Hopkins Medicine.

India contributes 20 per cent of the global deaths due to liver disease. Some studies suggest that 35 per cent of the citizens have a fatty liver as we follow traditional food habits along with a sedentary and modern lifestyle. Recent studies, especially the one by Kovai Medical Center and Hospital, Coimbatore, and co-authored by Dr Arulraj Ramakrishnan, show that liver inflammations are not an urban phenomenon anymore. The study, published in The Lancet, is titled ‘Prevalence of abnormal liver tests and liver fibrosis among rural adults in low and a middle-income country: A cross-sectional study’, and proves that liver infections are rising among hardworking rural Indians too. Children in urban areas are also not immune. A survey of Delhi students conducted by Apollo Hospitals and the INCLEN Trust says that of the 961 children aged 5 to 10 examined, from across 13 private schools, over 22 per cent of the children in the normal weight range had non-alcoholic fatty liver disease. Of the overweight children, 45.6 per cent had NAFLD. Early in August, a report from Mumbai said a 16-year-old Vile Parle resident was diagnosed with liver cirrhosis, and doctors say she is among the hundreds of teens who contract acute liver infections among the thousands who get a fatty liver, all because of the consumption of junk foods and lack of exercise.

Dr Aabha Nagral, hepatologist and senior consultant at Apollo and Jaslok hospitals in Mumbai, is one of the trustees of the Children’s Liver Foundation whose mission is to bridge the general lack of awareness about liver disease, “especially in children who hence suffer from delayed or missed diagnosis as well as a lack of access to appropriate treatment options.” Nagral certainly doesn’t consider the disease of the liver as a mere hype since the condition is a marker for many other health problems, including debilitating and lethal ones.

Dr Nagral says that for a disease that was largely associated with alcoholism, these days she comes across numerous cases of NASH and NAFLD, which she thinks is also because more people are doing preventive medical check-ups. She says that some 20 per cent of those with fatty liver get infections, a condition that needs urgent attention, which is essentially lifestyle changes. She is also worried about later-stage infections that include liver fibrosis, cirrhosis, and cancer. The shortage of donors accentuates the problem when a patient needs to go for a liver transplant.

Liver infections are symptoms of other conditions, including diabetes, a health scourge in India, which accounts for the largest number of patients in a single country. The fact that Indians have a genetic predisposition for developing fatty liver despite being thin (called lean NASH, in the absence of overweight and obesity) compounds the problem as one that is too dangerous to ignore.

Covid simply made things worse. The pandemic season, which is still ongoing after more than two years, sees people suffer poor health in more ways than one: people fall sick and are forced to isolate and give up healthy lifestyle habits like exercise, some die, and many others suffer from long-term effects of the virus. Many people who had Covid symptoms are now approaching hospitals for full-body checks, and many of them, including teens, are discovering hidden health conditions due to an inactive lifestyle caused by the viral disease.

The challenges don’t end there. The bad news is elsewhere too.

As mentioned earlier, the study by Dr Arulraj Ramakrishnan and others states that rural Indians are highly susceptible to NASH, which was once seen as the disease of the rich and the city-bred.

He says of the study published this year, “We did not see an association between alcohol consumption and liver damage, but that does not mean it can be ruled out. The clear association between being overweight, diabetic, and having liver damage is something well-postulated in the Western world, but why it happens among rural hardworking farmers could only be explained theoretically, some of which do not have scientific validation.”

Dr Ramakrishnan goes on to list the causes for rural men and women getting liver diseases: “Irregular eating times, I think, is a culprit. We need to be eating more during the day. The tradition in villages is a late breakfast, lunch followed by a nap, and a big dinner followed by immediate sleep. To put it simply, the unspent calories get stored as fat in the liver leading to fatty liver disease. The answer would be to eat when we work, and not at times of rest.” He adds that most often rural food is carbohydrate-based and of late, they have become more refined. “And hence, although the quantity of food is the same, the quality is changed and contains more carbohydrates,” he avers. Another theory, he suggests, for the spike in liver diseases in the countryside is that the usage of insecticides and fertilisers changes the gut microbiota, similar to changing the soil microbiota. “But at this point in time, it is rather a postulation without any scientific validation,” he hastens to state.

In the next stage of their research, Dr Ramakrishnan and his team hope to study how many people with a fatty liver end up having liver infections, including cirrhosis. “It will take a year or so,” he notes. Meanwhile, he pauses for a moment to underscore the link between liver diseases and other life-threatening ailments like acute diabetes and heart diseases, just as many practitioners have done. “The theory,” he says, “is fascinating.” He points out, “The unspent calories get deposited in the liver, and it becomes fatty. Slowly, it develops insulin resistance.” He likens it to a knock being less audible on the other side of a heavily coated door. “Similarly, the fatty liver requires more and more insulin similar to knocking against a heavier door, and this leads to the development of diabetes as time goes by. The vice versa is also true, diabetes leads to more fat deposition in the liver.”

Further, he adds, “We can measure fat deposition in the liver, but in blood vessels, we don’t, and it is actually a surrogate marker for fat elsewhere in the body, including the blood vessels. At an individual risk point, the fatty liver indicates the heart is at immediate risk—by that, I mean in the next five to 10 years—but the liver risk is over 10 to 20 years.”

While many liver experts blame injudicious consumption of ayurvedic drugs as a cause of liver diseases, Dr Nagral is of the view that there is no turf war or a move to run down alternative medicine. “I think it is made to look like a turf war, but it has been proven that self-medication of giloy (Tinospora cordifolia), a herbal supplement advertised vigorously by various brands as an immunity booster to prevent Covid, has shown liver injury in some patients,” she says, adding that some allopathic medicines also cause liver infections in people. According to her, there is a subset of people with autoimmune conditions who develop liver injuries when they have immunity boosters. “Which is why self-medication is a major hazard,” Dr Nagral says, emphasising that all streams of medicine must work together to address this health crisis. She advocates phased trials in ayurvedic medicines, too, to ensure that there is data to attest to safe use. In fact, the paper, ‘Tinospora Cordifolia (Giloy)-Induced Liver Injury During the COVID-19 Pandemic-Multicenter Nationwide Study from India’, co-written by Anand V Kulkarni, spotlights the problem with giloy consumption.

As much as there are challenges with herbal medicines sold by unscrupulous manufacturers, there are also disputes over the excessive use of certain allopathic medicines, especially those used to treat the coronavirus. Thrissur, Kerala-based ayurvedic doctor Krishna Das notes that Azithromycin is responsible for drug-induced liver injury, just as intake of turmeric in large quantities is. He also believes that many herbal medicines came up during the pandemic by those looking to hit paydirt, and should be avoided, as should the consumption of ayurvedic drugs without medical advice. Also, if you get Hepatitis A or B along with fatty liver, liver failure is the most likely outcome. Hepatitis, or inflammation of the liver, is caused, among other reasons, by alcohol consumption, but the main cause is viral infection. For his part, Dr Ramakrishnan feels that in India, the use of complementary medicine is a significant risk, both as a cause of acute liver damage in people without existing liver damage and also for worsening liver disease with existing liver damage. He, however, adds, “This is seen in hospital practice rather than community, and hence our study would not have addressed it.”

Marion Nestle, an academic and public health expert whose books on food habits have attracted much attention, had long warned us, along with the likes of Michael Pollan, that with the food market in the West showing saturation, companies were heading to emerging markets to make money, “regardless of the effects of their products on the health, welfare and agricultural systems of the countries they are targeting.” Nestle had also said that while she was on a visit to India, she was amazed by the presence of food MNCs in far-flung areas. With the assault of such giants, Indians are exercising less and less in a sort of inertia from Covid times. A corrective lifestyle can definitely help reverse the damage in the early stages, as doctors state. But merely popping Vitamin E tablets isn’t the solution to the progressive health condition of the organ the size of a football that helps digest food and expel toxic substances. As always, lack of awareness continues to foreshadow India’s continuing health crises.

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