Untold damage How even teetotallers could be putting their livers at risk
One in five people are in the early stages of non-alcoholic fatty liver disease – but don’t know it. Victoria Lambert reports
Hilary Todd was astonished when doctors told her in December 2015 that she needed an urgent liver transplant. “I felt fine,” she says, “I told them, I’m not ill. I really didn’t believe it.”
Yet the 53-year-old, who lives in Woodton, Norfolk, had nonalcoholic fatty liver disease (NAFLD), caused by a build-up of fat which, over time, had caused the liver to fail.
Having never drunk alcohol, and being “overweight, but fit from running around the playgroup I ran and from looking after my own three children”, the diagnosis “was a surprise” – all the more so when she was told that she needed “to get on the transplant list while I was still well enough to have the operation. By the time I was ready in October 2016, my main hepatic portal vein was so blocked, I was two weeks away from being inoperable.”
Todd had an advanced case of fatty liver disease – in up to 12 per cent of cases, NAFLD develops into non-alcoholic steatohepatitis or NASH which can lead to liver cirrhosis – severe scarring – and liver cancer. Her initial diagnosis, however, is surprisingly common; though most people associate the condition with excessive alcohol intake, the British Liver Trust estimate that more than one in five people in the UK are now in the early stages of NAFLD. Most will have no idea they are even at risk.
“Alcohol is still the most common cause for admission to hospital with liver disease,” explains Dr Phil Harrison, consultant hepatologist at London Bridge Hospital’s Liver Centre, “but now it’s closely followed by NAFLD.”
He puts this down to the rise in obesity – more than 60 per cent of British adults are now classed as such – and cases of type 2 diabetes, projected to rise by one million by 2035, both of which predispose to NAFLD, leading the condition to become “a serious problem, almost an epidemic”. Most cases will have a BMI of over 30, classifying them as obese. But NAFLD also shows up in those with BMIS of 25-30 – the overweight category.
“NAFLD takes up the bulk of our outpatient clinic work,” agrees Professor Jonathan Fallowfield, senior clinical fellow and honorary consultant hepatologist at the University of Edinburgh. “Over the last decade, we’ve noticed it becoming more prominent and it will soon be the most common reason for liver transplants.”
He says that the public “don’t realise the significance” of what is happening, and are only usually diagnosed after being “picked up with abnormal liver tests after being investigated for something else. They’re often overweight or obese but they may have no symptoms.”
Men are more likely to suffer NAFLD than women, with older people, lower-income families and those who drink a little too much most at risk. It can affect anyone, however, and last summer, it was revealed that fatty liver disease was a contributing factor to the death of singer George Michael.
It is not fully understood yet, says Dr Harrison. “The fat which gets deposited is not the same as fat we see around the waist. It gets into the liver cells where it can stop the liver doing its work of detoxifying.
“Often, liver disease progresses insidiously for years building into inflammation. In time, the worst symptoms can be brain confusion, jaundice, or bleeding from swollen veins in the oesophagus.”
Bleeding was the first symptom Hilary Todd suffered, but as it started when she was 43 – most people are not considered at risk until they are in their 50s – doctors couldn’t detect an underlying problem.
After a family trip to the local swimming pool 10 years ago with her three children, “I threw up a sink full of blood in the changing room. It was frightening,” Todd says. She was taken to hospital with a suspected bleeding ulcer, and suffered a stroke the next day.
After three days in intensive care, she was diagnosed with oesophageal varices (enlarged veins in the gullet) but liver biopsies – the most effective way to diagnose the condition – were inconclusive.
She spent the following seven years being monitored regularly, but it was only in late 2015, when a blood test indicated her condition had deteriorated, that Todd was placed on the transplant list.
As liver transplants are the only cure for advanced liver disease, the main aim of doctors is to encourage weight loss. When his 69-year-old mother, Sunila, was diagnosed with liver disease, marketing director Asanka De Silva began developing Livon!, a £1.99 coffee drink low in calories, sugar and fat, to help tackle the issue. “The only thing useful for liver health with any clinical evidence behind it is drinking coffee,” he says by way of explanation for creating Livon! It’s not fully understood how coffee benefits the liver, though a 2016 report from the British Liver Trust found that consumption of moderate amounts may prevent the cancer, while five cups a day could potentially cut the risk of liver disease by 80 per cent.
“It’s crucial to remember that much liver damage is reversible,” says Professor Fallowfield. “When people lose between 7 and 10 per cent body weight through dieting or weight-reduction surgery, NASH resolves dramatically. It’s never too late.”
Sugar is a problem, Dr Harrison adds, and “we need to watch our weight and avoid too many carbohydrates and keeping calories down.”
‘Five cups of coffee a day could cut the risk of liver disease by 80 per cent’
NASH is becoming increasingly common among children. “By 2020, it’s estimated half of all children will be overweight or obese”, which, Professor Fallowfield explains, “is down to both environmental and genetic factors. But in many cases it is an entirely preventable illness.”
Work is now going on to establish how the disease progresses from fat in the liver to cirrhosis, he adds. “If we can work out what makes NAFLD develop into a serious problem in some people, we can find new treatments.”
Until then, patients like Hilary Todd have no choice but to hope a liver transplant is found. Todd underwent the 10-hour operation in May 2017, which left her “in and out of the hospital for five months afterwards. I had bleeding from my spleen, a stomach bug, sepsis.”
Things have since settled, though she is monitored every two months “and I do get very tired. But you have to look at the alternative and get on with your life. I warn people now, look after your liver.”