It is time to pay heed to the emerging threat of NAFLD.

MINISTER of Health, Datuk Seri Dr. S Subramaniam recently alluded to preventable deaths from fatty liver and reminded Malaysians to be aware of the current scourge of this relatively new disease that can lead to end stage liver disease and liver cancer.

Many lives could be saved from prevention and early detection.

The Malaysian Liver Foundation (MLF) is in fact fully aware of this emerging threat, and later on this year, will be organising a one-day symposium on fatty liver.

Doctors are urged to attend so that they can help their patients who have fatty liver by providing them with the latest information, proper treatment and advice.

Fatty liver usually refers to Non-Alcoholic Fatty Liver Disease (NAFLD) to distinguish it from fatty liver due to excessive alcohol consumption or other secondary causes.

It is increasingly recognised worldwide and is now the most common liver disorder in countries where obesity, type 2 diabetes mellitus, dyslipidaemia and metabolic syndrome are common.

There is already global concern regarding the increasing prevalence of obesity and fatty liver, and this has now taken centre stage since obesity is a common associated risk factor.

Obesity has in fact become a major public health problem of the 21st century. In Malaysia, 60% of the population is either overweight or obese. Fatty liver tends to be more common in this group, although it can also occur in people with normal weight, especially if they have other associated diseases.

The incidence of fatty liver is expected to increase with increasing sedentary lifestyles and changing dietary patterns of the population.

It gets serious if it is associated with inflammation in the liver. The occurrence of fatty liver is influenced by age, gender and ethnicity, and most patients are diagnosed in their 40s or 50s.

Older patients with fatty liver are likely to experience more severe disease with progression to advanced fibrosis and earlier deaths.

Fatty liver was once thought to be a benign condition. However, new studies have revealed that patients with fatty liver have increased overall mortality compared with matched control populations.

The most common cause of death in patients with fatty liver is actually cardiovascular disease rather than liver-related complications.

But patients with the more serious variety called Non-Alcoholic Steatohepatitis (NASH) are likely to have long term complications such as cirrhosis, liver failure, hepatocellular carcinoma (HCC) and increase in liver-related mortality.

Most patients with fatty liver have no symptoms. Those with NASH, however, may complain of fatigue, malaise and vague right upper abdominal discomfort.

In addition, patients often have findings associated with other disorders that may accompany the disease, such as diabetes and hyperlipidaemia.

Fatty liver is suspected if a patient has increased liver enzymes without an obvious cause, or an abdominal ultrasound done routinely detects it.

Doctors of course must exclude other causes of fatty liver or liver diseases by taking a thorough history from the patient. In particular, they have to exclude excessive alcohol consumption or concurrent medication.

Once the diagnosis is made, patients should get proper advice and counselling from their doctors. They should not press the panic button as not many will progress to the more serious variety, NASH.

Known risk factors such as obesity or diabetes type 2 must be managed well.

Most doctors would recommend lifestyle modification as the first mode of treatment because patients with fatty liver are linked with other metabolic conditions such as obesity, insulin resistance, type 2 diabetes mellitus and hyperlipidaemia.

Treatment should be more aggressive in patients with NASH while those with fatty liver alone have an excellent prognosis and should only be followed up regularly.

Weight loss for those who are overweight and increased physical activity can lead to sustained improvement in liver enzymes, histology, serum insulin levels, improved fatty liver on imaging studies and quality of life.

A reasonable goal for many patients is to lose 0.5 to 1 kg/week. More rapid weight reduction may be associated with worsening of liver disease.

Patients with fatty liver are at increased risk for cardiovascular disease and often have multiple risk factors. It is important therefore that in the overall management of patients with fatty liver, blood glucose control in patients with diabetes must be optimised, and hyperlipidaemia, if present, should be treated.

Several drugs including anti-diabetic agents, statins, vitamin E and others have been recommended, but there is no conclusive data to support them yet.

More work, including dedicated research, needs to be done and these will be discussed at the forthcoming fatty liver symposium.

Tan Sri Dr Mohd Ismail Merican is president of the Malaysian Liver foundation. For more information, contact the Malaysian Liver Foundation at tel: 03-7842 6101; fax: 03-7842 6107; e-mail:; or website: