4 in 10 Hyderabad adults carry fatty liver, obesity is biggest driver: Lancet

Hyderabad: The city recorded a 40.9 per cent prevalence of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD), placing Hyderabad slightly above the national average (38.9 per cent) in a large-scale screening that examined over 10,000 adults across India.

The findings emerged from the Phenome India cohort study, which screened residents across 27 Indian cities between December 2023 and June 2024. Researchers published the results in The Lancet Regional Health – Southeast Asia.

Of every 10 adults screened in Hyderabad, four carried excess fat in their livers alongside metabolic risk factors like obesity, diabetes, high blood pressure or abnormal cholesterol levels. The city’s prevalence matched closely with other major southern metros, including Bengaluru at 40.6 per cent and Chennai at 41.2 per cent.

MASLD prevalence of 38.9% across India

The nationwide study found an age-adjusted MASLD prevalence of 38.9 per cent across India. Researchers identified 3,712 MASLD cases among 7,764 participants included in the final analysis.

“MASLD affected over one-third of participants,” the researchers noted in the study.

Men in Hyderabad showed a higher prevalence than women. The study recorded 46 per cent prevalence in men compared to 36.2 per cent in women, reflecting a pattern seen across most Indian cities.

What is MASLD?

MASLD, previously known as non-alcoholic fatty liver disease or NAFLD, received its new name in 2023 to better reflect that metabolic dysfunction drives the condition. The name change moved away from defining the disease by what it is not, focusing instead on the metabolic problems that cause it.

The condition develops when fat accumulates in liver cells alongside metabolic problems like obesity, diabetes, high blood pressure or abnormal cholesterol levels. Simple fat accumulation can progress to inflammation, then to fibrosis as scar tissue forms, and eventually to cirrhosis or liver failure in severe cases.

Most individuals showed no symptoms until reaching advanced stages, when liver function begins to decline. The silent progression makes community screening critical for early detection.

“These figures highlight the subclinical nature of early MASLD and its silent progression, which poses a potential burden to the public health systems if left unaddressed,” the researchers wrote.

Researchers from the Council of Scientific and Industrial Research(CSIR), including Hyderabad-based CSIR-CCMB, conducted the study, recruiting permanent staff members, retirees and their spouses from 37 CSIR laboratories across the country. All participants provided voluntary consent.

The team used transient elastography, a technique that measures liver stiffness and fat content without invasive procedures. The method allowed large-scale community screening without requiring liver biopsies.

Researchers collected clinical, biochemical and anthropometric data alongside liver measurements. Participants underwent blood tests measuring glucose, cholesterol, triglycerides and other metabolic markers. Staff measured weight, height, waist circumference and hip circumference using standardised equipment.

Liver fibrosis

The study also examined liver fibrosis, a more advanced stage of liver damage where scar tissue replaces healthy liver cells. Significant fibrosis appeared in 2.4 per cent of the overall population and in 6.3 per cent of individuals with MASLD.

Fibrosis clustered among older adults, people with diabetes, and those with severe obesity. Among people with diabetes, 9.1 per cent showed fibrosis. Among individuals with class II obesity, 8.1 per cent showed fibrosis.

Southern cities showed intermediate to lower MASLD prevalence compared to central and northern India. Thiruvananthapuram recorded the lowest rate nationally at 27 per cent, while Chennai and Bengaluru reported just over 40 per cent.

Mysore and Karaikudi showed prevalence below 40 per cent. Women in southern India carried a higher relative burden than women elsewhere, with post-menopausal women facing increased risk, pointing to hormonal and metabolic influences.

Southern and eastern regions also recorded lower liver fibrosis prevalence, even where MASLD rates were moderate. In contrast, central and northern cities such as Srinagar, Bhopal, Roorkee, Ghaziabad, and Jammu showed the highest disease burden, underscoring strong regional and gender-based variation across India.

Obesity drives disease, diabetes amplifies risk

Obesity emerged as the strongest driver of disease nationwide. Individuals with class II obesity faced nearly fourteen times higher odds of MASLD compared to those with normal weight. Diabetes more than doubled the risk, while high blood pressure and abnormal cholesterol levels further increased vulnerability.

“Obesity was observed to be the predominant driver of MASLD in India, with additional contributions from diabetes, dyslipidemia, elevated blood pressure, and central adiposity,” the study stated.

Among the 3,712 MASLD participants nationwide, 66.4 per cent of individuals with diabetes carried the condition. The study found 1,280 of 1,927 people with diabetes had MASLD.

“In our study, 66.4 per cent of participants with diabetes had MASLD, while 9.1 per cent had fibrosis,” the researchers noted.

The research identified a subset of lean MASLD, where individuals with normal body weight still developed fatty liver disease. These cases appeared in association with diabetes and central obesity, challenging assumptions that fatty liver affects only visibly overweight individuals.

“Our data also confirm the presence of lean MASLD, particularly associated with Type 2 diabetes, likely reflecting greater visceral rather than subcutaneous adiposity,” the researchers wrote.

The age-adjusted prevalence in females stood at 33 per cent and in males at 45.9 per cent across the country. Men showed higher overall prevalence than women, though the pattern varied in some regions.

The study examined 48 cytokines and found that 40 showed higher levels in the MASLD group compared to those without the condition. Molecules associated with inflammation, including IL-7, IL-8 and CXCL10, appeared approximately two-fold higher in individuals with fibrosis.

“The transition to fibrosis may be accompanied by an intensified inflammatory milieu,” the study stated.

The researchers called for policy changes to address the growing burden.

“The high prevalence of MASLD and liver fibrosis in India represents an urgent public health challenge. Our findings advocate for policy shifts to include transient elastography-based screening, especially for urban and high-risk populations,” the authors said.

They recommended training healthcare workers to use transient elastography and integrating liver screening with existing metabolic disease programs.

“Training healthcare workers to use transient elastography and integrating it with existing metabolic disease programs could enhance scalability,” the study stated.

The authors warned that without intervention, the rising burden of MASLD and fibrosis could strain India’s healthcare system, increasing risks of cirrhosis, liver cancer and cardiovascular disease.

They urged policymakers to consider population-level screening strategies, particularly for urban groups at high risk, alongside lifestyle and metabolic risk reduction measures.

Large-scale interventions

“Community-based awareness and targeted public health interventions across diverse geographical and socio-cultural settings in India may help curb the rising burden,” the authors concluded.

The study called for longitudinal research to track trends in MASLD and liver fibrosis over time and evaluate the impact of screening interventions.

“Future longitudinal studies are needed to track trends in MASLD and liver fibrosis and evaluate the impact of screening interventions,” the authors said.

The Phenome India cohort comprises predominantly urban, educated individuals, largely drawn from CSIR employees and their families. Most participants belonged to urban and semi-urban middle and higher-middle income groups.

The researchers acknowledged this limitation. “The Phenome cohort may not be able to fully capture the socio-economic, educational, and rural diversity of the broader Indian population,” they wrote.

The study excluded individuals reporting any alcohol consumption to ensure accurate MASLD classification by removing potential confounding from alcohol-related liver injury.