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 Table of Contents  
EDITORIAL
Year : 2020  |  Volume : 1  |  Issue : 2  |  Page : 75-77

Fatty liver disease is a neglected non-communicable disease in world health organization global action plan for prevention and control of non-communicable diseases 2013–2020: A call for policy action


1 Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Community Medicine, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
3 Director, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
4 President, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission09-Sep-2020
Date of Decision28-Sep-2020
Date of Acceptance28-Sep-2020
Date of Web Publication15-Dec-2020

Correspondence Address:
Dr. Ajeet Singh Bhadoria
Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_156_20

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How to cite this article:
Bhadoria AS, Mishra S, Kant R, Nundy S. Fatty liver disease is a neglected non-communicable disease in world health organization global action plan for prevention and control of non-communicable diseases 2013–2020: A call for policy action. J Med Evid 2020;1:75-7

How to cite this URL:
Bhadoria AS, Mishra S, Kant R, Nundy S. Fatty liver disease is a neglected non-communicable disease in world health organization global action plan for prevention and control of non-communicable diseases 2013–2020: A call for policy action. J Med Evid [serial online] 2020 [cited 2021 Jan 19];1:75-7. Available from: http://www.journaljme.org/text.asp?2020/1/2/75/303553



With the turn of century, dramatic modifications in lifestyle have radically changed health priorities in most parts of the world. Resultantly, the predominant epidemiological characteristics have transitioned from infectious diseases to non-communicable diseases (NCDs). Globally, in 2017, NCDs accounted for an estimated 41·1 million deaths (95% uncertainty levels (UI): 40.4–41.5) representing 73.5% (95% UI; 70.8%–75.7%) of all deaths.[1] To reduce premature NCD mortality by one-third by 2030 is an ambitious target under Sustainable Development Goal (SDG) 3.4.[2] The indicator is, however, narrowly defined for including only four major NCDs (cardiovascular diseases [CVDs], cancer, diabetes mellitus [DM] and chronic respiratory diseases).

Today, chronic liver diseases (CLDs) are representing a major public health problem. The current worldwide estimations show that CLDs, compared to other major public health problems namely, DM (422 million, 1.6 million deaths),[3] pulmonary diseases (650 million, 6.17 million deaths)[4] and CVD (540 million, 17.7 million deaths),[5] are affecting 844 million individuals with a mortality rate of 2 million deaths per year;[6] a large sub-set of these CLD-related deaths are avertable and premature. This implies that, like other chronic diseases, CLD-related deaths can also be (i) prevented through effective health policies and population-based interventions by focusing on wider determinants of health, namely, behavioural, biological, and environmental risk factors, and socioeconomic status (preventable mortality), and (ii) avoided/postponed following access to high-quality care once disease ensues in (amenable mortality).[7],[8]

CLD-related amenable mortality are mostly viral (chronic hepatitis C [CHC], chronic hepatitis B [CHB]) or fatty liver in origin.[9] Due to recent advances in anti-viral therapy (against CHC) and compulsory vaccination drive (against CHB), viral-induced CLDs are declining; raising concerns to visualise fatty liver disease (FLD) characterising as the most frequent causal factor for CLD sooner or later. With alcoholic liver disease (ALD) and non-alcoholic FLD (NAFLD) as the common underlying aetiologies, incidence of FLD is anticipated to show rising trends with ongoing lifestyle changes and unhindered rise in DM and obesity incidence at both global and country levels. Beyond this, FLDs (alcoholic or non-alcoholic) is a known potent contributor to hepato-cellular carcinomas (HCC). Despite this, the World Health Organization (WHO) skipped to incorporate concrete actions against FLD in their ongoing global action plan for NCDs (2013–2020).[10] In the wake of it, the present commentary aims to revisit FLD that substantiates it as the widely contemplated precursor of lifestyle diseases requiring due attention at global level.

FLD represents a wide histological spectrum of liver diseases/injuries with abnormal intra-hepatic fat accumulation as a common underlying denominator. It occurs as a result of perturbation in the homeostatic mechanisms that regulate synthesis versus utilization of fat in liver.[11] Recently, FLD has been identified as a hepatic manifestation of lifestyle diseases. Earlier most FLD was seen contemplating in men and women consuming =30 g and =20 g alcohol/day for at least 5 years' duration, respectively, diagnosed as alcohol-related liver disease (ALD). Later, FLD was seen even amidst the absence of no significant alcohol intake; all remaining causes other than alcohol intake alone were clubbed together under the common head–NAFLD.[12] Various other risk factors have been identified associated with greater likelihood of developing NAFLD; in general, these are mostly those that also predict the occurrence of CVDs in adults.[10],[13] The histologic spectrum of FLD is seen ranging widely from initial stages of fatty liver (hepatic steatosis; also the preventive stage) to advanced stages of inflammation (steato-hepatitis; also identified as the red-flag sign), fibrosis, cirrhosis, HCC which may ultimately succumb to liver transplantation (LT) and/or even death. For an individual suffering from end-stage liver disease (ESLD), sometimes, LT is the only way to save the patient's life. LT in India is a high-cost procedure; amounting to 2–3 million rupees in the country and is not covered under any health insurance schemes including Ayushman Bharat.[14],[15] Thus, FLD inducing LT is likely to pose additional threat on the financial capacities for Indian families that can pull them down to below poverty line owing to out-of-pocket expenditures.

NAFLD is a heterogeneous group of NAFLD disorders that encompass FLD spectrum in individuals without significant alcohol consumption. Beyond inherited metabolic disorders and drug-induced liver injury, NAFLD is seen contemplating in association with sub-components of metabolic syndrome (MS) (obesity, Type II DM, dyslipidaemia, insulin resistance and hypertension).[12] Like any other NCDs, NAFLD too reflects many gaps in the understanding of its natural history – absence of a known agent, multi-factorial causation, long latent period, and indefinite onset – making it another potent NCD that needs further detailed consideration. Due to long-standing association with other major organs beyond liver (heart, kidney), the NAFLD-MS combination represents one of the most potential deadly threat of accentuating cardiovascular, oncologic and liver-related multi-systemic events that can add to large economic burden, and associated poor quality of life.[9] As consumption of alcohol is also lifestyle-related, it is very likely that NAFLD-ALD co-exists in today's scenario; experiencing severity worse than those with ALD or NAFLD alone. NAFLD identified in children is the recent inclusion, reflecting on the impending complications. Moreover, NAFLD is also seen affecting the non-obese termed as “lean NAFLD.”

The highest estimated worldwide prevalence of CLDs amenable to prevention is observed due to NAFLD in almost half the cases with highest observed in Western countries (17%–46%) where it is the most common CLD in adults;[16] in India, its prevalence is seen ranging between 9% and 35% amongst general population.[17] This is followed by ALD in 8.5% with highest prevalence (~12%) in Europe and the United States (US),[18] CHB in 3.6%, ranging from 0.5% in European countries to >8% in sub-Saharan Africa,[19] and finally, CHC in 2.5%, ranging from 1.8% in the US to 5.6% in Africa.[18] The accurate respective prevalence of NAFLD is, however, not well known because of the lack of accurate liver histology information (diagnostic gold standard) from most studies.[9] In a recent systematic review and meta-analysis, the overall prevalence of NAFLD in Asian population regardless of diagnostic method is reported as 29.6% (95% confidence interval [CI]: 28.13–31.15).[20] The prevalence of NAFLD is seen increasing significantly over time ([25.3%; 95% CI: 22.4–28.4 between 1999 and 2005], [28·5%; 95% CI: 26.7–30.3 between 2006 and 2011], and [33.9%; 95% CI: 31.7–36.1 between 2012 and 2017]; P < 0·0001). The pooled annual NAFLD incidence rate is 50.9 cases per 1000 person-years (95% CI: 44.8–57·4). In patients with NAFLD, the annual incidence of HCC is 1.8 cases per 1000 person-years (95% CI: 0.8–3.1) with overall mortality rate as 5.3 deaths per 1000 person-years (95% CI: 1.5–11.4).[20] In near future, with these rising trends, it is expected that FLD (more specifically NAFLD) will become the leading cause of ESLD i.e., cirrhosis and HCC and consequently, the most frequent indication for LT. The prevalence of NAFLD as an aetiology for CLD and LT is seen rising during 1999–2004 (63% and 9.8%, respectively) and 2005–2008 (75% and 11%, respectively), making it the third most common indication for LT in the US after CHC and alcohol.[21] In this regard, exclusion of deaths as a consequence to CLDs, directly or indirectly,[9] from SDG target is controversial and needs immediate perusal.

FLD is a silently progressing disease that goes mostly undiagnosed in the absence of mandatory screening. Most FLD deaths are due to CVDs-related; though associated morbidity due to cirrhosis and HCC also needs equivocal attention. This calls for urgent interventions that can be incorporated against FLD; most of which are same meant for other NCDs. These are (i) public awareness; (ii) weight management along with other lifestyle modification strategies (dietary and physical activity) and (iii) reduction in harmful alcohol consumption. More specific interventions covers: (i) Early detection of FLD in premature stages with ultrasonography (USG); (ii) Followed by regular screening with fibroscan or other simple non-invasive biochemical markers such as alanine aminotransferase (ALT), aspartate aminotransferase (AST)/ALT ratio and AST/platelet count ratio have proven effective in combination to early detect fibrosis in early stages of FLD.[10]

Given the rapidly growing global burden of FLD, efforts must continue to identify its accurate non-invasive screening and diagnostic tools with prognostic biomarkers validated for Indian population. In the past two decades, significant improvements have occurred in the overall understanding of FLD's natural history. Better insights are, however, required to acquire new scientific knowledge for FLD prevention, diagnosis and appropriate management for mass implementation specific to Indian settings. As ALD and NAFLD are likely to co-exists, it would be better to employ large-scale FLD screening as a whole with available checklist used in national programme for NCDs at lower health-care levels (sub-centre and primary health centres). Tools like fibroscan/USG can be reserved for secondary healthcare level (community health centres and district hospitals) and above for its best utilization in identification of fatty liver and the associated inflammation at initial stages of the disease. This will enable more detailed risk stratification and development of rational diagnostic pathways to avert its progression to advanced stages. Public awareness and participation by health-care systems and authorities are crucial to reach this goal. Indeed, such mass interventions require global support and political will. However, if international health organizations such as WHO considers and includes above interventions in their upcoming global action plan against NCDs, this can act as a platform for all member countries including India to work in this direction more comprehensively.



 
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