If you were to ask anyone in the UK what the main killer of 35–49-year-olds was, chances are not many people would say non-alcoholic fatty liver disease (NAFLD). It is the by-product of obesity and diabetes - two conditions everyone knows about. But practically no-one has heard of NAFLD.
That’s soon going to change whether we like it or not.
Liver disease is on the rise and is the fastest growing cause of death in the UK compared to other major killers, such as heart disease and cancer, where the number of deaths has either remained stable or decreased.
It is also one of the fastest growing diseases globally, occuring in about one in four people around the world. And it is now the biggest cause of chronic liver disease. Experts predict that over the next decade, NAFLD will become the leading cause of end stage liver disease and liver transplantation. It is already the fastest growing cause of hepatocellular carcinoma, the commonest form of liver cancer worldwide.
Risk factors for the disease include obesity, type 2 diabetes, high blood pressure, high cholesterol, advanced age and a current smoking history.
The world is sitting on a ticking public health time bomb and must race to both prevent and treat this disease before the epidemic worsens and overwhelms health systems.
On the surface some things are being done, albeit in an ad-hoc way. Campaigns to prevent obesity are nothing new and measures like the UK government’s ban on junk food advertising on TV and online before 9PM are welcome.
The state of Oaxaca in Mexico has also provided a potential policy model for other countries to follow with legislation prohibiting the sale of junk food and soft drinks to unaccompanied minors. This move was partly a response to the high levels of severe illness and death from Covid-19 in young people with conditions such as diabetes.
It has been well documented how hard the pandemic has hit people with chronic diseases and this should serve as a wake-up call to policy makers around the world to introduce policies to prevent obesity and diabetes. These policies must become ingrained in public health and, more importantly, have teeth.
Two things must happen to change the dial on NAFLD.
Firstly, governments must be more proactive and take on the food processing giants to force them to be more transparent about both the nutritional value and sugar content of their products.
There have been some successes. The public debate in the UK a few years ago around sugar levels in orange juice led to a government imposed sugar tax. The UK government has also introduced a traffic light system of red labels for unhealthy products and green labels for healthier items.
But other countries, such as Chile, have taken a much tougher approach, enforcing front-of -pack labels that warn of high sugar, salt and fat levels on snacks, soft drinks and packaged food. A fall of almost a quarter in sugary drink sales seems to show that the policy is working.
Front-of-pack nutrition labelling is set to be a continuing battle zone in broader efforts to promote healthy diets long term, building on the campaign work of people like celebrity chef Jamie Oliver and footballer Marcus Rashford.
When footballing mega-star Cristiano Ronaldo replaced a Coca-Cola bottle with a bottle of water at a Euro 2020 press conference earlier this year, his three-second cameo reverberated around the world, perhaps unlocking possibilities for future campaigns encouraging people to take better care of what they eat and drink.
Secondly, specialists and non-specialists alike must come together to raise awareness of the disease, which, among diabetes doctors and GPs, is shockingly low. It means we are missing opportunities for early detection and intervention.
One of the challenges facing doctors is early diagnosis of the disease. NAFLD is largely asymptomatic in its early stages and many people do not know they have it unless it is caught during unrelated tests. However, there have been recent encouraging developments in screening tools.
Just as challenging are medical interventions to respond to NAFLD cases. At present there is no approved pharmacological treatment for NAFLD. A number of clinical trials are underway but there is a huge disparity between the amount of research into the disease and the growing urgency around it.
As things stand, a national policy for NAFLD is lacking in almost every country in the world. These are sorely needed if we are to reduce stigma around a disease that is so closely associated with obesity.
A recent study confirmed that NAFLD could also be passed down from obese mothers to their offspring. That should be motivation enough for us to effect generational change and break the obesity-NAFLD cycle.
- Thomas Berg is the Secretary-General of the European Society for the Study of the Liver (EASL) who are this week hosting the Digital NAFLD Summit 2021.
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