Fatty Liver Disease—Don’t take your liver for granted!

The liver is an organ that never stops working, yet most of the time, we pay minimal attention and care to it. The liver plays numerous pivotal roles ranging from aiding digestion, protein and enzyme production, and detoxifying the body. 

Even with a minor liver injury, insult, or stress, the liver continues to stay resilient and functions without symptoms. It is only when the liver is more than 2/3 damaged that symptoms start to show. Hence, taking care of the liver is paramount. In this article, we discuss a common reversible cause of liver damage—fatty liver disease.

Why is our liver so important to us? What is the function of the liver?

The liver is located just below the lungs and over the right upper part of the abdomen –the region is also known as the right hypochondrium. It plays a vital role in:

• Producing proteins, albumin, and cholesterol
• Storing glucose in the form of glycogen (the main source of energy for our body)
• Storing iron and vitamins of the body
• Removing and processing waste, toxins, medications, and alcohol
• Producing clotting proteins to regulate body haemostasis which prevents abnormal bleeding
• Producing bile to digest fat

What is fatty liver disease?

Fatty liver disease, also known as steatosis of the liver, is a medical condition that occurs due to the accumulation of fat in the liver. There are two types of fatty liver disease, these are:

• Alcoholic fatty liver disease: occurs in individuals with a history of excessive alcohol intake. 
• Non-alcoholic fatty liver disease (NAFLD): most common type of fatty liver disease and usually occurs in individuals who do not drink excessive amounts of alcohol.

There is a strong association of NAFLD with metabolic conditions such as obesity, hypertension, diabetes, and dyslipidaemia. Some medical journals suggest fatty liver is the hepatic manifestation of metabolic syndrome.

What are the 4 stages of non-alcoholic fatty liver disease?

Non-alcoholic fatty liver disease occurs in approximately 40% of Singaporeans and comprises four different stages, these are: 

• Stage 1, simple fatty liver: presence of additional fats accumulating in the liver cells. Patients are generally asymptomatic; however, they can have mild or abnormal liver blood tests. 
• Stage 2, non-alcoholic steatohepatitis (NASH): 10-25% of patients with fatty liver can progress to a benign, non-aggressive condition associated with inflammation of the fatty liver (known as steatohepatitis).
• Stage 3, fibrosis: condition where scar or fibrotic tissues begin to form on the inflamed liver cells. The liver cells may still be able to function normally.
• Stage 4, cirrhosis: a third of patients with NASH may progress onto an irreversible stage where normal liver cells are replaced by fibrotic-scarred cells, leading to the disruption of normal liver function. Eventually, in severe cases, one can develop liver failure, liver cancer (hepatocellular carcinoma) or even death.

How do I know if I have fatty liver disease?

Patients with a fatty liver are usually asymptomatic. However, if you notice the following symptoms, it could be a sign that your fatty liver disease has progressed: 

• Abdominal pain
• Mild nausea
• Difficulty tolerating fatty food
• Loss of appetite
• Unintentional weight loss
• Exhaustion
• Yellowish skin and whites of the eyes

If you notice the above symptoms, make an appointment with your doctor immediately.

What causes fatty liver disease in non-alcoholics?

Non-alcoholic fatty liver disease is associated with the build-up of excess fats in the liver. This occurs when more calories are consumed than the body can use, the excess calories are converted to fats and stored in the liver. When the amount of fats in the liver is more than 5% of the liver’s weight, then fatty liver disease occurs. 

There is also a strong association between non-alcoholic fatty liver disease and non-alcoholic steatohepatitis with metabolic syndrome.

This means that individuals are more predisposed to fatty liver disease if they have:

• Elevated body mass index or obesity
• High glucose level (hyperglycaemia), history of insulin resistance, prediabetes, or type 2 diabetes
• Elevated cholesterol, in particular high levels of triglycerides

As most patients are asymptomatic, routine health screening or a medical checkup is encouraged to screen for metabolic syndrome and NAFLD. You are encouraged to discuss with your doctor on your possible risk factors and what can be done to reduce your risk of developing fatty liver disease.

What are the risk factors of developing NAFLD?

Medical conditions that increase an individual’s risk for developing NAFLD include:

• Metabolic syndrome
• Elevated cholesterol, in particular high triglyceride levels
• Obesity
• Type 2 diabetes
• Polycystic ovarian syndrome (PCOS)
• Sleep apnoea
• Endocrine conditions such as thyroid disease

How common is fatty liver disease in Singapore?

With the rise of metabolic syndrome, obesity, and diabetes, the cases of NAFLD are rising exponentially as well. Currently NAFLD is becoming the most common cause of liver disease in the world. A study conducted in 2022 found that the prevalence of NAFLD is estimated to be 32.4%, with numbers expected to grow. 

In Singapore, the prevalence can be as high as 40%. Interestingly, not only can NAFLD be seen in obese people, but also in 20% of non-obese Asians. 

Why should I screen for fatty liver/NAFLD?

As NAFLD can progress into irreversible complications such as cirrhosis (severe scarring of the liver), regular routine screening is important in the prevention of fatty liver disease.  

Once an individual has developed liver cirrhosis, further complications may occur such as a buildup of abdominal fluid (ascites), oesophageal vein swelling and rupture (varices), liver encephalopathy (with change of mental state, confusion, drowsiness), increased risk of liver cancer (hepatocellular carcinoma), and end stage liver failure.

Hence, it is very important to detect and treat NAFLD when it is still in its early, reversible stages. Thankfully, the progression of the condition is generally slow, and most NAFLD patients are stable and can be managed in primary care. Do speak to your doctor to screen for NAFLD.

How is fatty liver/NAFLD diagnosed?

Fatty liver can go undiagnosed for years as it usually does not cause pain or other symptoms. One usually picks up fatty liver findings during routine blood tests.

If your results are concerning to your doctor, he/she may arrange an ultrasound of the liver. In severe cases, your doctor may refer you to a gastroenterologist who will then advise for a liver fibroscan or biopsy for further evaluation of the extent or severity of your fatty liver disease.

When should I screen for fatty liver/ NAFLD in Singapore?

You should consider screening for fatty liver/NAFLD if you have any of the following conditions: 

• Underlying metabolic syndrome
• Diabetes
• Increased cholesterol level

What should I expect when I see my doctor for fatty liver/NAFLD?

Your doctor will usually take your medical history and examine you physically— covering blood pressure, weight, height, waistline measurement, etc. Depending on how you fare, your cardiovascular organs and liver may also be screened.

Subsequently, blood tests which cover the general screening, and a liver function test are conducted to screen for metabolic syndrome and fatty liver disease. Depending on your individual risk factors, you may also be required to have imaging (e.g., ultrasound, CT scan, MRI) taken of your liver. You can discuss your concerns with your doctor regarding NAFLD and decide on any suitable tests for further evaluation.

What should I do if I have fatty liver/NAFLD?

NAFLD is a reversible condition if managed early, below are some steps you can take to reverse or prevent fatty liver disease. 

• Exercise: aerobic and resistance training exercises have been clinically proven to be effective in controlling and potentially reversing NAFLD with just 7-10% of weight loss. Generally, a gradual weight loss of 0.25-0.5kg weekly is advised, until you reach your targeted individual ideal weight. A woman should aim for a waistline of 80 cm or less, while a man should aim for a waistline of 95 cm or less.

• Healthy diet: a diet low in fats and carbohydrates but high in fibre is encouraged.
• Reduce alcohol: avoid alcohol completely or minimise your alcohol intake.

Medications: medication may be prescribed for the concurrent management of diabetes, cholesterol, or blood pressure problems. Medications may also be prescribed to individuals with recalcitrant visceral fat/chronic elevated BMI in order to facilitate weight loss.