India contributes to 20% of the global deaths due to liver disease. Nearly 1/4th of our adults are either overweight or obese (at risk of fatty liver disease) and alcohol use is also on the rise. About 70% of the Indian population lives in rural areas and nearly 50% of them are physically active, agricultural workers - traditionally believed - not to be at risk for liver disease.
WHO's definition of health has 2 parts: Subjective, a state of complete physical, mental and social well-being and objective, the absence of disease or infirmity. Our paper published in "The Lancet - eClinicalMedicine" journal tries to address objectively, the presence of liver disease in rural India.
We tried to answer three issues in the previously undefined rural population from India - the prevalence of abnormal liver tests, the major causes of abnormal liver tests and the prevalence of liver cirrhosis (the stage before onset of liver disease). We found that the prevalence of abnormal liver tests and cirrhosis of 8% and 1% respectively is similar to western world. Meticulous screening for all possible causes of liver diseases ruled them out and enabled us to show a clear association between liver damage and obesity/diabetes. Although the absence of not doing gold standard liver biopsy is a limitation but understanding its infeasibility helped us realise non-invasive assessment of liver disease in rural India was achievable.
The latest national family health survey portrays the increasing prevalence of metabolic syndrome, obesity and diabetes in India. Our paper highlights another facet of metabolic syndrome, fatty liver disease and it being present even among physically active rural population who are traditionally believed not to be at risk of these health issues.
The presence of significant liver damage, even in people with normal liver tests during screening, was an eye opener. It made us realise that normal liver tests may falsely reassure people at risk of liver disease, and benefits of further assessment outweigh the costs of further assessment as shown in the image below.
Early screening for the presence of liver disease seems to be the way forward with adoption of healthy lifestyle by avoiding regular alcohol intake irrespective of the quantity, daily exercises and watchful eating.
The National Program for Prevention and Control of Cancer, Diabetes, CVD and Stroke (NPCDCS) has incorporated fatty liver disease into NPCDCS screening but it appears more has to be done in this area given the scale of the healthcare burden of advanced liver disease and unaffordable associated costs to a common man.
The study by the KMCH liver unit was done with guidance from Prof James Neuberger, Birmingham, UK and funded by KMCH research foundation.
(Dr. Arulraj Ramakrishnan is a UK trained hepatologist, now in Kovai Medical Centre and Hospitals, Coimbatore, India.)
Disclaimer: These are the personal opinions of the author.