Debate on preventing obesity and fatty liver disease

Fatty liver disease

The debate is being held on International NASH Day (non-alcoholic steatohepatitis). This is a public education campaign, launched in 2018, which seeks to raise awareness and action surrounding NASH – an advanced form of fatty liver disease. The campaign is owned by the Global Liver Institute, and supported by the British Liver Trust.

Background

Non-alcoholic fatty liver disease (NAFLD) is a term used to describe several conditions which are cause by a build-up of fat in the liver.

Some groups of people are at an increased risk of developing NALFD, these include people who are:

• are obese or overweight – particularly if you have a lot of fat around your waist (an "apple-like" body shape);
• have type 2 diabetes;
• have a condition that affects how your body uses insulin;
• are insulin resistance, such as polycystic ovary syndrome;
• have an underactive thyroid;
• have high blood pressure;
• have high cholesterol;
• have metabolic syndrome (a combination of diabetes, high blood pressure and obesity);
• are over the age of 50;
• smoke.

People with early-stage NAFLD are unlikely to experience any symptoms. In more advanced stages (see below), people may experience:

• a dull or aching pain in the top right of the tummy (over the lower right side of the ribs);
• extreme tiredness;
• unexplained weight loss;
• weakness.

NAFLD is distinct from alcohol-related liver disease which results from excessive alcohol consumption.

NAFLD can be diagnosed after a liver function test is performed using a blood sample, or via an ultrasound scan of the tummy. Further tests can be performed to determine how advanced the condition is.

Disease progression

Early-stage NAFLD does not usually cause harm, but it can lead to serious liver damage, including cirrhosis, if it gets worse.

NAFLD develops in four main stages:

1. simple fatty liver (steatosis) – a largely harmless build-up of fat in the liver cells that may only be diagnosed during tests carried out for another reason
2. non-alcoholic steatohepatitis (NASH) – a more serious form of NAFLD, where the liver has become inflamed
3. fibrosis – where persistent inflammation causes scar tissue around the liver and nearby blood vessels, but the liver is still able to function normally
4. cirrhosis – the most severe stage, occurring after years of inflammation, where the liver shrinks and becomes scarred and lumpy; this damage is permanent and can lead to liver failure (where your liver stops working properly) and liver cancer

People with NAFLD can go onto to develop non-alcoholic steatohepatitis (NASH). This is an aggressive form of fatty liver disease, which is characterised by liver inflammation and may progress to advanced scarring (cirrhosis) and liver failure. The damage is similar to that caused by heavy alcohol use.

Treatment

There is no specific treatment for NAFLD, but affected people are advised to maintain healthy lifestyles.

Healthcare professionals may try to ensure that associated conditions, such as high blood pressure, diabetes and high cholesterol, are being properly managed or treated.

The National Institute for Health and Care Excellence (NICE) has published a guideline on the assessment and management of NAFLD (NG49, July 2016). This says that clinicians should advise people with NAFLD, who are overweight or obese, on physical activity and diet, in line with NICE’s guidelines on obesity (CG189, September 2022) and preventing excess weight gain (NG7, March 2015). The guideline on NAFLD also advises on medicines to be used in advanced liver fibrosis (scarring).

Further information:

• NHS, Non-alcoholic fatty liver disease (NAFLD)
• Mayo Clinic, Non-alcoholic fatty liver diseases

Government policy

When asked what steps it had taken to improve pathways for the early detection of liver disease, the Government highlighted “£2.3 billion of capital funding has been allocated for investment in diagnostic services, to increase capacity for the diagnosis of liver disease”. This was a reference to the Spending Review 2021, where the Government committed to this funding to “transform diagnostic services with at least 100 community diagnostic centres (CDCs) across England to permanently increase diagnostic capacity and help patients receive lifesaving checks close to their homes”.

This followed the Government’s earlier commitment to 44 community diagnostic centres in 2021-22, of which 32 were intended to be outside London and the South East of England.

In May 2023, the Government announced locations for six new CDCs across the East of England, Midlands and the South East. The Government said 106 CDCs were open across England, and that its £2.3 billion investment would deliver up to 160 centres across England by 2025.

It was reported in May 2023, that Health Secretary Steve Barclay was refusing to approve approximately 30 CDCs on the basis that they had scheduled opening dates beyond 2023.

In March 2023 NHS England highlighted a pilot scheme to check for liver damage in the community, targeting areas across England where the population is at particularly high-risk. Mobile trucks are visiting GP practices, recovery services, food banks, diabetes clinics, sexual health clinics and homeless shelters to perform quick, non-invasive scans. The checks are being offered to adults with high levels of alcohol consumption, a current diagnosis or history of past viral hepatitis, or non-alcoholic liver disease, as these factors increase the risk of developing liver cancer. The initiative started in June 2022 and the trucks are expected to visit and scan 22,000 people during the first year of the pilot scheme.

The Government has previously said the prevention of NAFLD and support for patients with this condition to reduce their risk falls under the Government’s strategy to reduce obesity.

Obesity

Background on obesity as a health condition, its management, prevalence and the Government’s policy on reducing its prevalence are available in the Library’s briefings on obesity and obesity statistics.

Obesity and fatty liver disease

The British Liver Trust has warned that “rocketing rates of obesity are putting millions at risk of an advanced form of fatty liver disease”.

The British Liver Trust, the All-Party Parliamentary Group on Liver Disease and Liver Cancer, and Liver Cancer UK, are collectively calling for the Government to improve prevention and early diagnosis of liver disease, and reduce health inequalities that could contribute to the incidence of liver disease:

Prevention: Upstream interventions and population wide measures are urgently needed to shape the food and drink environment and reduce obesity as a driver of rising liver disease burden.

• Reformulation of unhealthy food and drink products underpinned by government regulation.
• UK government to deliver on existing policy commitments not yet implemented, including implementing the 9pm watershed plans to protect children from junk food advertising on TV and online and the ban on multibuy junk food deals. Health inequalities:

• UK government to deliver a clear set of policies to ‘level up’ liver disease to meet its ambition to narrow the gap in Healthy Live Expectancy (HLE) between areas where it is highest and lowest by 2030 and deliver a 5-years increase in HLE by 2035.
• A prompt and comprehensive review of adult liver services by NHS England to tackle huge inequalities and geographic variation in treatment outcomes and care. Early diagnosis:

• A new nationally endorsed pathology pathway to improve early diagnosis of liver disease.
• Every Community Diagnostic Centre (CDC) to have an assessment for fibrosis.
• NHS health check to routinely include assessment for non-alcohol related fatty liver disease.
• Patients with advanced NAFLD need access to weight management services, irrespective of BMI and in line with access to services for people with diabetes.

The organisations also called for the Government to improve the healthcare workforce.

During a Commons debate on the diagnosis of liver disease and liver cancer (October 2022), then Parliamentary Under-Secretary of State for Health and Social Care, Dr Caroline Johnson, highlighted work being undertaken by Government to prevent obesity:

Tackling obesity is a major priority for the Government. We have seen some important successes since 2016. The average sugar content of drinks subject to the soft drinks industry levy decreased by about 43% between 2015 and 2019. This month, regulations have been brought in about store placement of products that are high in fat, salt and sugar, so that they cannot be displayed in areas of the store that are attractive and available to children. There have also been the provisions set out in the Calorie Labelling (Out of Home Sector) (England) Regulations 2021 and an investment in further weight management services for people living with obesity.