Why fatty liver disease could be the next public health crisis

For such patients the only effective treatment is liver transplantation, which requires lifelong immunosuppression. Based on the severe consequences of NAFLD, there are some very worrying statistical trends: more than half of adults and one-third of children in Europe are now classified as being overweight or obese, with the highest proportion coming from lower socio-economic groups.

As a consequence of these rising levels of obesity, NAFLD has now become the most common cause of liver disease in Western countries, affecting one in four people.

In a proportion of people, NAFLD can cause progressive liver damage, and in some cases it may even lead to the development of liver cirrhosis and liver cancer. Although the risks for any given individual are low, because the numbers of people that are overweight or obese are so large, NAFLD currently accounts for one in seven liver transplants in the UK.

In the US it is now the most common indicator for a liver transplant. People with NAFLD are often also at increased risk of heart disease and a range of other types of cancer. If left unchecked, the annual predicted cost of NAFLD in Europe is estimated to be greater than €35 billion in direct costs to the health system, and a further €200 billion by way of wider costs to society.

More generally, liver disease is now the most common cause of premature mortality in the UK and notably is the only one of the top five causes of mortality.

Despite these dire statistics, awareness that obesity and diabetes can contribute to significant liver disease is low amongst the public and the healthcare community, as is knowledge of appropriate and effective everyday life changes that can help or even reverse liver disease.

There is a pressing need to better communicate the liver-related risks of obesity and type 2 diabetes mellitus to patients and general practitioners. Unfortunately, there remains a strong stigma associated with both obesity and liver disease which commonly adds to the burden of disease, reducing the likelihood that people will engage with health services to seek treatment and support.

An urgent expansion of knowledge and skills is needed amongst healthcare providers on the high prevalence of NAFLD and associate stigma, risk factors, how to conduct nutrition screening and counselling, and engaging patients in appropriate behaviour change initiatives. Fortunately, there is much that can be done.

The causes of obesity and NAFLD – sedentary behaviour and unhealthy diets – are avoidable. This is a preventable epidemic. Tackling these conditions will require us to take a much broader view of the upstream causes and the many factors at play. Public discussion of obesity places great emphasis on personal responsibility, yet this approach has manifestly failed to reduce the problem.

A societal re-think is required if we are going to make a real impact on obesity, with a focus on tackling the drivers of the epidemic, while also educating the public in relation to healthy behaviours and the risks of obesity.

The Cameron and May governments both identified obesity as a major health threat to the UK and have instigated a number of important measures. Including the levy on sugar-sweetened beverages (SSBs), which was designed to promote reductions in the sugar content of these drinks.

Other proposed measures include legislation that ensures better labelling and composition of processed foods. Another challenge is to reduce children's exposure to marketing that promotes foods and drinks high in energy, saturated fats, trans-fatty acids, added sugar or salt.

Food and beverage advertisements, particularly those embedded in children’s TV programmes, digital and social media, have been shown to drive up consumption of high-calorie and low-nutrient beverages and foods.

Collectively this has led to proposals in some countries, including the UK, to restrict the advertising and marketing to children of SSBs and industrially processed foods high in saturated fat, sugar and salt.

No one intervention will succeed in reversing the trends in obesity, diabetes, or liver disease – if we are to succeed in promoting a healthier population, we will need the availability of healthy food, safe streets and parks, healthy schools, and specifically combinations of all of these and more.

The feted Mediterranean Diet for example, characterised by a high intake of olive oil, nuts, fruits, vegetables and fish, and a low intake of red and processed meat and added sugar, may well be one future effective solution for the management of obesity and NAFLD but its attractiveness needs to be proactively 'sold' to the consumer.

Just as big a challenge is the acute need to improve the diagnostic tools for NAFLD. The disease is currently assessed by liver biopsy, an invasive, costly and risky procedure. The lack of non-invasive biomarkers has hampered patient care and impeded drug development by complicating conduct of clinical trials.

Additionally, the identification and diagnosis of NAFLD is made worse by the lack of effective biomarkers to identify which patients have developed the disease and which have progressed to a more advanced stage.

Blood-based biomarkers for staging and grading NAFLD are particularly attractive for population level disease screening, providing they have high sensitivity and specificity. 

Currently, work is being carried out by researchers to develop, robustly validate and advance towards regulatory qualification biomarkers that diagnose, risk stratify and/or monitor NAFLD/NASH progression and fibrosis stage. We need biomarkers as urgently as we need prevention and better diagnosis if we are to avoid what is looming as the next public health crisis

• Philip N. Newsome is Secretary General of the European Association for the Study of Liver Disease (EASL) and Director of the Centre for Liver and Gastrointestinal Research & Professor of Hepatology at the University of Birmingham.

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