Profiling donors for his patients requiring a liver transplant threw up surprising results for Dr Arvinder Singh Soin, chairman and chief surgeon, Medanta Liver Institute, Gurugram. “Most patients aged between 45 and 65, who have liver failure and require an organ transplant, turn to their children to be their donors. Now our study showed that 50 per cent of their children or even young prospective donors from an extended family, usually between the ages of 20 and 40, had fatty liver, combined with stressors like a poor lifestyle and being overweight. It was a small study with our patient pool but was fairly representative. About a half of young Indians have fatty liver,” he says.

Many of these individuals appeared healthy. They were young, active and had never imagined they might be harbouring a liver condition. Yet beneath the surface, years of sedentary living, poor food choices, inadequate exercise, chronic stress and increasing obesity had already begun to leave their mark.

The discovery prompted Dr Soin and his team to ask an important question. If these young adults had developed fatty liver largely because of lifestyle factors, could the condition be reversed quickly enough to make them suitable donors? To find out, he launched a second study.

“We put them on GLP 1 drug semaglutide and GLP1 and GIP combination drug tirzepatide on 2.5 mg dose, both of which mimic the function of natural gut hormones. Simultaneously, we put them on an aggressive lifestyle change. Then we did a second study on them,” says Dr Soin. What we found was interesting. Existing medical literature has evidence that weight loss medication with lifestyle changes can speed up the weight loss process in six to eight weeks. “Here a combination of the two accelerated weight loss after two weeks…. As a result, their fatty liver condition was reversed. So that was our second revelation, that GLP-1 weight loss drugs can just be accelerators, the heavy lifting for a healthy liver still needs to be done by lifestyle correction,” he adds.

One of the biggest misconceptions surrounding fatty liver disease is that it affects only people who are visibly overweight. Increasingly, doctors are diagnosing what is known as “lean fatty liver” in individuals whose weight falls within the normal range.

According to Dr Soin, a young individual with a body mass index (BMI) below 24 may still have a 20 to 30 per cent risk of developing fatty liver. “With bad lifestyle, that risk goes up to 50 to 70 per cent. Genetics may play a role, but so do hidden metabolic abnormalities such as insulin resistance, low muscle mass and excess abdominal fat. The result is that a person can look fit from the outside while the liver silently accumulates fat within,” he says.

For decades, dietary fat was considered the principal villain in discussions about liver disease. Today, evidence increasingly points to another offender: sugar. Modern diets contain enormous quantities of hidden sugars, often consumed unknowingly. They are found not only in sweets and desserts but also in soft drinks, packaged fruit juices, energy drinks, breakfast cereals and a wide range of ultra-processed foods. “Particularly concerning is fructose, which is metabolised primarily in the liver. Excessive fructose consumption encourages the liver to convert sugar into fat, gradually contributing to fatty liver disease,” he says.

The conversation around fatty liver often centres on diet and exercise. However, Dr Soin believes two equally important factors frequently escape attention: chronic stress and inadequate sleep. “Poor sleep can make you three to four times more prone to developing fatty liver,” he says. Lack of sleep (less than seven hours) keeps the body’s stress response switched on for prolonged periods. Elevated levels of cortisol and adrenaline increase insulin resistance, one of the key drivers of fatty liver disease.

Many people judge their health by their body weight alone. But when it comes to fatty liver, where fat is stored often matters more than how much a person weighs. Abdominal fat, particularly the visceral fat that accumulates around internal organs, is strongly associated with fatty liver and insulin resistance. A person may maintain a normal body mass index while carrying dangerous amounts of visceral fat. “This is why waist circumference and waist-to-hip ratio have become increasingly important markers of metabolic health. They often provide a more accurate picture of risk than body weight alone,” says Dr Soin.

The most deceptive aspect of fatty liver disease is its silence. Most patients experience no symptoms during the early stages. “Because it causes little immediate discomfort, many assume it is a harmless condition. Yet over the course of 10 to 20 years, fatty liver can set the stage for a cascade of serious health problems, including diabetes, cardiovascular disease, liver fibrosis, cirrhosis and liver failure. One lesser-known fact concerns liver cancer. Many people believe liver cancer develops only after cirrhosis. In reality, some patients can develop liver cancer even when they have only early-stage fibrosis and relatively mild liver damage,” says Dr Soin.

Given the silent nature of fatty liver disease, Dr Soin advocates a more proactive approach to screening, particularly among adults over 30. “Body composition assessments such as DEXA scans can provide valuable insights into visceral fat and muscle mass. Combined with routine blood tests and imaging studies, they can help identify risk before irreversible liver damage occurs.”

Early detection is important because fatty liver remains one of the few chronic diseases that can often be reversed if addressed in time. “The liver possesses an extraordinary ability to recover when the factors driving injury are removed,” he says.

That recovery begins with lifestyle correction. Given the magnitude of the problem, Dr Soin doesn’t mince words. “Eliminate alcohol and smoking together from your 20s. Both are carcinogenic and toxic and pose equal threats. Have one to two cups of black coffee a day. Reduce sugar consumption drastically, avoid ultra-processed foods, prioritise protein-rich meals, exercise regularly and maintain healthy sleep habits. This is all it takes to reverse fat accumulation within the liver. Strength training, ideally beginning in early adulthood (20s) and continued throughout life, plays a particularly important role in preserving liver health,” he explains.

The challenge is recognising the problem before the liver begins paying the price for years of neglect.