Public health response to non-alcoholic fatty liver disease

Public health Response to Non-alcoholic Fatty Liver Disease (NAFLD)

Non-alcoholic fatty liver disease (NAFLD) has become more common, increasing diabetes and metabolic syndrome worldwide. NAFLD is a group of liver disorders that range from non-alcoholic fatty liver (NAFL) to non-alcoholic steatohepatitis (NASH) and can develop into cirrhosis and liver cancer. ^[1]

NAFLD is predicted to affect 25% of the world's population, with the Middle East and South America having the highest frequency and Africa having the lowest8. Even though the BMI cut-off for diagnosing overweight in Asia (BMI > 23) is lower than in North America and Europe (BMI > 25), a large percentage of individuals with 'lean NASH' in Asia have an average body mass index (BMI). ^[1]

A study conducted by Lazarus et al. ^[2] looked into the Public Health response to NAFLD across the different countries in Europe. Twenty-nine countries had been considered for the study. NAFLD or NASH were mentioned in existing initiatives in two nations (obesity and alcohol). Ten said they had national clinical guidelines particularly treating NAFLD and that all of them contained recommendations for diabetes and liver cirrhosis assessment if the disease was diagnosed. According to eleven countries, all individuals with diabetes, obesity, or metabolic syndrome should be screened for NAFLD. Five countries had primary care follow-up and specialist referral algorithms, while seven nations had structured lifestyle programmes targeting NAFLD. Seven had contributed to public awareness efforts aimed at preventing liver disease. Four countries reported having NAFLD-related civil society organisations, while three nations have NAFLD-related national registries. In the examined European countries, a comprehensive public health response to NAFLD was found to be missing. It comprises policy in the form of a plan, clinical recommendations, public awareness campaigns, civil society participation, and the organisation of health systems, including registries.

A need to address  NAFLD as a public health crisis is crucial. Furthermore, a strengthened public health system is required to facilitate the same.

Reference

1. Friedman SL, Neuschwander-Tetri BA, Rinella M, Sanyal AJ. Mechanisms of NAFLD development and therapeutic strategies. Nature medicine. 2018 Jul;24(7):908-22.

//www.nature.com/articles/s41591-018-0104-9

2. Lazarus JV, Ekstedt M, Marchesini G, Mullen J, Novak K, Pericàs JM, Roel E, Romero-Gómez M, Ratziu V, Tacke F, Cortez-Pinto H. A cross-sectional study of the public health response to non-alcoholic fatty liver disease in Europe. Journal of hepatology. 2020 Jan 1;72(1):14-24.

//www.sciencedirect.com/science/article/pii/S0168827819305215

A number of studies have found a positive relationship between hyperinsulinemia, abnormal glucose tolerance, and NAFLD.

Mishra et al found the prevalence of metabolic syndrome and NAFLD to be 24% and 14.8%, respectively, in non-alcoholic North Indian men

In a study by Mohan et al the prevalence of NAFLD (54.5%) was significantly higher in patients with diabetes compared to those with pre-diabetes  (33%), and normal glucose tolerance
 

the prevalence of most cardio-metabolic risk factors was significantly higher in NAFLD patients. 
it has been found that mild, moderate, and severe NAFLD was present in 65.5%, 12.5%, and 9.35% of otherwise asymptomatic type 2 diabetics, respectively.

 Prashanth et alfound a high prevalence of NAFLD and NASH in type 2 diabetics which increased with multiple components of the metabolic syndrome.Mitra S, De A, Chowdhury A. Epidemiology of non-alcoholic and alcoholic fatty liver diseases. Transl Gastroenterol Hepatol. 2020 Apr 5;5:16. doi: 10.21037/tgh.2019.09.08. PMID: 32258520; PMCID: PMC7063528.

As seen in other studies, mean total cholesterol and LDL levels did not correlate with NAFLD; there was a significant correlation
with high triglyceride and low HDL levels. We found a higher mean carotid intimal-medial thickness (CIMT) in NAFLD patients. In an earlier study, we reported that, in type 2 diabetics, a mean CIMT above 0.8 mm was associated with a higher prevalence of CAD.

In the research article  “A cross-sectional study of the public health response to non-alcoholic fatty liver disease in Europe”, a survey was conducted among 29 European countries Norway, Switzerland and all European Union countries expect for Malta on policies, guidelines, awareness, monitoring, diagnosis and clinical assessment in their country. It was observed none of the participating countries have any official plan for Non-Alcoholic Fatty liver disease (NAFLD) .Only two countries have NAFLD and non-alcoholic steatohepatitis ( NASH)included in their obesity and alcohol guidelines. A comprehensive approach related to policies, guidelines, health system organization and epidemiological initiatives is lacking in participating European countries. As NAFLD is a growing public health challenge so  there is a need to raise awareness and attention towards NAFLD.

//www.journal-of-hepatology.eu/article/S0168-8278(19)30521-5/fulltext#t0005

Non- Alcoholic Fatty liver disease (NAFLD) is estimated to afflict approximately 1 billion individuals worldwide. The hepatic consequences of metabolic syndrome and obesity, non- alcoholic fatty liver disease (NAFLD), is estimated to affect up to one-third of the adult population in many developed and developing countries [1]. NAFLD is emerging as an important cause of liver disease in India. Epidemiological studies suggest the prevalence of NAFLD in around 9% to 32% of the general population in India with a higher prevalence in those with overweight or obesity and those with diabetes or prediabetes. Pilot studies on treatment strategies have shown that weight reduction and exercise, ursodeoxycholic acid, metformin, vitamin E and pentoxyfylline are effective in normalizing transaminases and or in improving hepatic steatosis and inflammation in Indian patients with NAFLD [2].

Dr Harsh Vardhan, Union Minister of Health & Family Welfare, launched the operational guidelines for integration of NAFLD with NPCDCS (National Programme for Prevention & Control of Cancer, Diabetes, Cardiovascular Diseases and stroke) on 22nd February 2021 [3]. The Government of India is of the view that existing NPCDCS programme strategies can be aligned to achieve the objectives to prevent and control NAFLD with:

• behaviour and lifestyle changes,
• early diagnosis and management of NAFLD,
• building of capacity at various levels of healthcare for prevention, diagnosis and treatment of NAFLD.

References:

[1] Anstee QM, Reeves HL, Kotsiliti E, Govaere O, Heikenwalder M. From NASH to HCC: current concepts and future challenges. Nat Rev Gastroenterol Hepatol. 2019 Jul;16(7):411-428. doi: 10.1038/s41575-019-0145-7. PMID: 31028350.

[2] Duseja, A. Nonalcoholic fatty liver disease in India – a lot done, yet more required!. Indian J Gastroenterol 29, 217–225 (2010). //doi.org/10.1007/s12664-010-0069-1&source=gmail&ust=1631124145307000&usg=AFQjCNGXrhO9kwlZ4r_gFcxghUlSHnzNy A"> //doi.org/10.1007/s12664-010-0069-1

[3] //pib.gov.in/PressReleseDetail.aspx?PRID%3D1699904&source=gmail&ust=1631124145300000&usg=AFQjCNEgA_QKOBBpA_pyXEy71dDft9vD0 Q"> //pib.gov.in/PressReleseDetail.aspx?PRID=1699904

Operational Guidelines for the integration of Non-alcoholic Fatty Liver Disease ( NAFLD) into NPCDCS:

//main.mohfw.gov.in/sites/default/files/OG%20print%20ready%20version%20.pdf

Posted by: @ashishjoshi

Lets share your views on the non alcoholic fatty liver disease prevalence and interventions.

pediatric non alcoholic fatty liver disease is the most common chronic liver disease in children with its prevalence rising in parallel with increase rates of overweight and obesity. It is a multisystem disease also affecting extrahepatic organs and it has a long term impact on health which extends into adulthood and causes significant morbidity and mortality. Lifestyle and dietary changes are currently the most effective treatment options for NAFLD. Losing weight ,being physically active ,cutting back on sugar ,eating a healthier diet and drinking coffee are some of the ways that may help improve symptoms associated with NALFD.

NAFLD is the most common form of chronic liver disease in adolescence affecting nearly 10–20% of the adolescent population. The major risk factors associated with NAFLD in adolescents and young adults are overweight and obesity associated with excessive refined food intake and physical inactivity. According to Epidemiological studies, the prevalence of NAFLD is around 9% to 32% of the general population in India. Researchers have found NAFLD in 40% to 80 % of people who have type 2 diabetes and in 30% to 90 % of people who are obese. If we look in view of the Ayushman Bharat programme Then the Ayushman Bharat programme has so far screened 838.39 lakh people, for hypertension, 683.34 lakh for diabetes, and 806.4 lakh for the three common forms of cancer through the HWCs. According to WHO, Worldwide more than 354 million people are living with chronic hepatitis; There are more than 8000 new infections of hepatitis B and C every day, and more than one million deaths from advanced liver disease and liver cancer each year.

//www.journalofdiabetology.org/article.asp?issn=2078-7685;year=2021;volume=12;issue=2;spage=218;epage=223;aulast=Mehreen

//pubmed.ncbi.nlm.nih.gov/21191681/

//www.who.int/news/item/28-07-2021-hepatitis-can-t-wait---who-commemorates-world-hepatitis-day-2021

Non-alcoholic fatty liver disease (NAFLD) is a general term for the liver diseases that occur due to storage of excess macro vesicular fat (>5% of the hepatocytes) because of a perturbation of the homeostatic mechanisms that regulate synthesis versus utilization of fat in the liver. It is a hepatic expression of a systemic disorder in which aberrant insulin action and resultant altered metabolic flux cause underlie inflammation that span multiple tissues and organ systems. Over the last two decades global burden of non-alcoholic steatohepatitis (NASH) has more than doubled. NASH caused 40 lakh prevalent cases of compensated cirrhosis in 1990 , which rose upto 94 lakh in 2017. NAFLD is emerging as an important cause of liver disease in India.

The Pooled global prevalence of NAFLD is 25.24%. The public health importance of NAFLD depends on its multifaceted impact on morbidity, all cause mortality and health care utilization in general population. Majorly, deaths in NAFLD are due to morbid obesity, cardiovascular disease while overall cancer mortality is also high in NAFLD. One of the most important aspects of Public Health interventions is to focus on modifying risk factors: to prevent and reduce obesity rates and to achieve better dietary habits. Policy measures such as taxation, especially of junk food, sugar-sweetened beverages, improving nutritional labelling, marketing regulation, reformulating food, conducting awareness campaigns as well as subsidies to increase consumption of healthier food have been proven to be successful in improving healthy eating among the general population, including children. Also, behavioural and lifestyle interventions that address both dietary habits and exercise at an individual level are likely to reduce obesity rates. Lastly, capacity building at various levels of healthcare for prevention, diagnosis and treatment of NAFLD is an essential public health intervention at a system level.

References:

1. //www.ncbi.nlm.nih.gov/pmc/articles/PMC7063528/
2. //www.journal-of-hepatology.eu/action/showPdf?pii=S0168-8278%2819%2930521-5
3. //pib.gov.in/PressReleasePage.aspx?PRID=1699904

NAFLD is an umbrella term used for a range of liver disorders which affect people who drink little or no alcohol. It is typically a hepatic manifestation of metabolic syndrome. Individuals with type 2 diabetes and obesity are prone to NAFLD. If patients with NAFLD are not treated on time, they develop aggressive form of fatty liver disease which progresses into cirrhosis. About 30% of Americans are affected by this disorder. China, Europe, Japan and the Middle East have ended up with obesity epidemic. Factors that contribute to NAFLD are as follows:

• Nutritional
• Genetic
• Sedentary lifestyle
• High-calorie and low-fiber diet

Interventions:

• Gradual weight reduction is a major way to manage NAFLD.
• Since sedentary lifestyle is closely associated with NAFLD, physical activity has profound effect in managing NAFLD. Walking, aerobics, bicycling, muscle toning and strengthening reduces intrahepatic lipid content and peripheral insulin resistance.
• Increased consumption of fruits and vegetables along with probiotic yoghurt is necessary, as they contain phenolic compounds and vitamins. Consumption of fatty acids and carbohydrates should be drastically reduced.
• Diabetes mellitus, obesity and hypertension should also be kept under control. 
• Obeticholic acid and Cenicriviroc have been used for treatment.

Thus, sufficient weight loss by exercise and diet is beneficial to cure NAFLD.

Citation

1. Ahmed IA, Mikail MA, Mustafa MR, Ibrahim M, Othman R. Lifestyle interventions for non-alcoholic fatty liver disease. Saudi J Biol Sci. 2019 Nov;26(7):1519-1524. doi: 10.1016/j.sjbs.2018.12.016. Epub 2019 Jan 3. PMID: 31762620; PMCID: PMC6864195.

2. Mundi MS, Velapati S, Patel J, Kellogg TA, Abu Dayyeh BK, Hurt RT. Evolution of NAFLD and Its Management. Nutr Clin Pract. 2020 Feb;35(1):72-84. doi: 10.1002/ncp.10449. Epub 2019 Dec 16. PMID: 31840865.

3. Neuschwander-Tetri BA. Therapeutic Landscape for NAFLD in 2020. Gastroenterology. 2020 May;158(7):1984-1998.e3. doi: 10.1053/j.gastro.2020.01.051. Epub 2020 Feb 13. PMID: 32061596.

Non-alcoholic fatty liver disease(NAFLD) is the accumulation of liver fat in people who drink little or no alcohol. It has a global prevalence of about 25% and is predicted to become the leading cause of cirrhosis requiring liver transplantation in the next decade. 

Risk Factors

A wide range of diseases and conditions can increase the risk of NAFLD, including:

• High cholesterol
• High levels of triglycerides in the blood
• Metabolic syndrome
• Obesity, particularly when fat is concentrated in the abdomen
• Polycystic ovary syndrome
• Sleep apnea
• Type 2 diabetes
• Underactive thyroid (hypothyroidism)
• Underactive pituitary gland (hypopituitarism)
• Gastric bypass surgery

It is imperative to identify patients with advanced disease using non-invasive markers of fibrosis, which include serology-based tests (eg NAFLD Fibrosis Score and ELF test) and imaging (eg transient elastography). This targets appropriate patients for referral to secondary care for additional investigations such as liver biopsy and specialist care.

Once the diagnosis for NAFLD is made, the focus should shift to treatment and monitoring for the development of associated complications. Given that currently no pharmaceutical intervention is approved for the treatment of NAFLD, focus shifts instead to mitigation of risk factors through avoidance of foods that are rich in red meat, trans fats, refined carbohydrates, and high-fructose corn syrup; are low fiber, and have high energy density.

Treatment options include:

• Lifestyle modifications and dietary interventions
• Medical therapies
• Weight loss
• Control of comorbid metabolic illness
• Endoscopic bariatric interventions
• Bariatric surgery
• Currently available pharmacological options include vitamin E, pioglitazone, and pentoxifylline

Although NAFLD in serious cases could lead to steatohepatitis, cirrhosis, and even liver failure, many people with NAFLD can lead normal lives as long as they improve their diet, exercise, and maintain a healthy weight.

Citation:

Maurice J, Manousou P. Non-alcoholic fatty liver disease. Clin Med (Lond). 2018 Jun;18(3):245-250. doi: 10.7861/clinmedicine.18-3-245. PMID: 29858436; PMCID: PMC6334080.

Mundi MS, Velapati S, Patel J, Kellogg TA, Abu Dayyeh BK, Hurt RT. Evolution of NAFLD and Its Management. Nutr Clin Pract. 2020 Feb;35(1):72-84. doi: 10.1002/ncp.10449. Epub 2019 Dec 16. PMID: 31840865.

Rinella ME, Sanyal AJ. Management of NAFLD: a stage-based approach. Nat Rev Gastroenterol Hepatol. 2016 Apr;13(4):196-205. doi: 10.1038/nrgastro.2016.3. Epub 2016 Feb 24. PMID: 26907882.

Liver diseases are fast emerging as global health priorities. Non-alcoholic fatty liver disease (NAFLD) is rapidly becoming the most common liver disease worldwide. The prevalence of NAFLD in the general population of Western countries is 20-30%. About 2-3% of the general population is estimated to have non-alcoholic steatohepatitis (NASH), which may progress to liver cirrhosis and hepatocarcinoma.

The prevalence of NAFLD is higher in males and increases with increasing age, and it is influenced by the diagnostic method and the characteristics of the population, especially lifestyle habits.The diagnosis of NAFLD in population studies is usually obtained by ultrasonography, which is known to underestimate the prevalence of fatty liver. The Dallas Heart Study and the Dionysos Study reported that 30% of the adults in the USA and 25% in Italy have NAFLD. In these studies, 79% and 55% of patients with NAFLD had normal aminotransferase levels, showing that liver enzymes are not surrogate markers of NAFLD in the general population. The most important risk factors for NAFLD are male gender, age, obesity, insulin resistance and the cardiometabolic alterations that define the metabolic syndrome.

The prevalence of NAFLD is

• 80-90% in obese adults
• 30-50% in patients with diabetes
• 90% in patients with hyperlipidemia

The prevalence of NAFLD among children is 3-10% and rises up to 40-70% among obese children. Moreover, pediatric NAFLD increased from about 3% a decade ago to 5% today, with a male-to-female ratio of 2:1. The incidence and natural history of NAFLD are still not well defined, but it is recognized that the majority of individuals with NAFLD do not develop NASH.

The accompanying adoption of a progressively sedentary life, consumption of diet dense in calories facilitate development of NAFLD while a spiraling upward trend in alcohol use along with earlier age of drinking as well as increased amount of per capita alcohol consumption increases the prevalence of ALD globally. The incidence of NAFLD is probably increasing in Western countries, strictly linked to lifestyle habits.

CITATION:

//pubmed.ncbi.nlm.nih.gov/20460905/

//www.ncbi.nlm.nih.gov/pmc/articles/PMC7063528/

The research article, "The Prevalence of Non-Alcoholic Fatty Liver Disease in Children and Adolescents: A Systematic Review and Meta-Analysis" narrative reviews of pediatrics NAFLD quote prevalence in the general population that range from 9% to 37%.They aimed to estimate prevalence of non-alcoholic fatty liver disease (NAFLD) in young people and to determine whether this varies by BMI category, gender, age, diagnostic method, geographical region and study sample size. 

Reference 

//journals.plos.org/plosone/article?id=10.1371/journal.pone.0140908

In this study , the NAFLD Preparedness Index indicates substantial variation between countries’ readiness to address NAFLD. Notably, even those countries that score relatively highly exhibit deficiencies in key domains, suggesting that structural changes are needed to optimize NAFLD management and ensure effective public health approaches are in place.

//www.jhep-reports.eu/article/S2589-5559(21)00010-0/fulltext