Expert Opinion by Dr. Lakshmi C.P., Consultant Gastroenterologist

Introduction

There’s a popular meme in Kerala joking that Malayalees have found a way to turn fatty liver medication into a convenient excuse to enjoy a drink. While funny, it reflects the alarming rise in liver-related conditions—many of which occur without alcohol consumption.

Traditionally, liver cirrhosis was viewed as a disease affecting heavy drinkers. However, growing cases among non-drinkers have led to a new classification: Non-Alcoholic Liver Cirrhosis.

What is Fatty Liver and How Does It Progress?

Fatty liver is a condition where excess fat builds up in liver cells. If this persists for 10–15 years, it can gradually lead to liver damage and eventually cirrhosis—a condition where liver tissues become permanently scarred.

Historically, cirrhosis was linked exclusively to alcohol abuse. Classic symptoms included vomiting blood, abdominal fluid accumulation, and severe fatigue. Today, we now know that even non-drinkers can develop cirrhosis, mainly due to metabolic factors.

From NAFLD to MASLD – A Shift in Understanding

Earlier, this condition was known as NAFLD (Non-Alcoholic Fatty Liver Disease) or NASH (Non-Alcoholic Steatohepatitis). However, international medical communities—especially in the West—raised concerns over the stigma associated with the word “alcoholic.”

Thus, in 2023, the terminology shifted to:
MASLD – Metabolic dysfunction-associated steatotic liver disease

This new name better reflects the underlying causes—like obesity, diabetes, and cholesterol—rather than focusing on alcohol intake.

Types of Steatotic Liver Disease

1. ASH – Alcohol-Related Steatohepatitis
   Seen in those who regularly consume alcohol. Alcohol causes fat to accumulate in the liver, eventually damaging it.
2. MASLD – Metabolic Syndrome-Associated Steatotic Liver Disease
   Occurs in people with no alcohol use but who have:
   • Obesity
   • Type 2 diabetes
   • High cholesterol
   • Insulin resistance
3. MetALD – A Hybrid Condition
   A newer category that includes individuals who:
   • Drink occasionally or moderately
   • Have metabolic risk factors like obesity or diabetes

In Kerala, MetALD is the most common variant, given the widespread presence of both lifestyle diseases and low-level alcohol use.

Why This Matters for Kerala

• Even non-drinkers in Kerala are commonly diagnosed with fatty liver.
• 65% of diabetics in the state have fatty liver, even if they are lean and controlled.
• High cholesterol, sedentary lifestyle, and genetics also play a role.

If fatty liver persists untreated, it can silently progress into liver cirrhosis over the years.

Why Early Detection & Awareness Matter

• Cirrhosis is irreversible once advanced.
• In early stages, it is silent and symptomless.
• Early intervention through lifestyle changes, weight loss, and medical monitoring can prevent long-term damage.

🩺 Dr. Lakshmi’s Advice

“We must stop assuming liver diseases are only caused by alcohol. Even a healthy-looking, non-drinking individual with diabetes or high cholesterol may silently develop liver damage over the years.”

Prevention Is Power

• Get regular liver function tests if you have diabetes or obesity.
• Avoid even occasional alcohol if you’re at risk.
• Maintain healthy cholesterol and body weight.
• Don’t ignore a fatty liver diagnosis—treat it like a warning signal.