Dr Ankur Garg, Group Director, Liver Transplant & GI Surgery, Paras Health, Gurgaon, explains how urban lifestyles can drive early liver damage.
It isn’t just the heart and the brain; the liver is also an integral part of the human system, essential for normal body functioning. In the initial phase, any liver disease does not have any significant symptoms, but as the disease progresses, one could see its manifestations and, in a few cases, lead to certain disabilities as well.
In recent times, with the type of lifestyle one follows, there could be ample chances for various organs to get affected without one’s knowledge.
Dr Ankur Garg, Group Director, Liver Transplant & GI Surgery, Paras Health, Gurgaon, writes how urban lifestyles can drive early liver damage.
For most of the last century, advanced liver disease in India meant chronic alcohol use or viral hepatitis. That assumption no longer holds. Hepatologists are now documenting hepatic injury in a much younger cohort, driven by metabolic dysfunction-associated steatotic liver disease (MASLD) — the condition formerly known as non-alcoholic fatty liver disease (NAFLD). Under the 2023 multisociety consensus, MASLD is defined by fat in more than 5% of hepatocytes and at least one cardiometabolic risk factor, placing metabolic dysfunction, rather than alcohol, at the centre of the diagnosis. Increasingly, it is detected in patients in their twenties and thirties, silently, years before symptoms appear.
The scale of the challenge is now well documented. The INASL guidance paper frames MASLD as a major and rising cause of chronic liver disease in India, with adult prevalence estimated near 38% and pronounced urban–rural variation. Globally, the most-cited review places adult prevalence at about 30%, having risen from 25% in 1990–2006 to 38% in 2016–2019. Among higher-risk Indian groups, the figures are steeper still: the MAP study recorded MASLD in 68.2% of diabetes-clinic attendees, with significant fibrosis in roughly a third. These are not abstract numbers; they describe a growing share of the patients who will pass through India’s clinics over the coming decade.
What makes this issue a priority, rather than simply a clinical curiosity, is the age at which the disease now appears. A Global Burden of Disease analysis of adults aged 15–39 found the burden rising steadily from 1990 to 2021 and projected to climb further to 2035, describing the trend toward younger onset as alarming. India’s position is central to the global picture: one comparative study found that India, China and the United States together account for 33.2% of global MASLD DALYs and 34.7% of deaths, with India carrying the heaviest load of the three — roughly 194 million prevalent cases in 2021, the highest DALY count and the most deaths, and the steepest rise in incident cases, about 141%, since 1990.
MASLD is not a disease of the old or the intemperate; increasingly, it is a disease of the young and the outwardly healthy.
This epidemic has consequences well beyond the clinic. Because most of India’s rising burden reflects demographic expansion, absolute case numbers will keep growing for years even as age-standardised rates stabilise. Disease that establishes itself in the third decade of life affects people during their most productive years, and the World Economic Forum has estimated that non-communicable diseases could cost India around USD 3.55 trillion between 2012 and 2030. Seen this way, acting early on MASLD is not only good medicine but also sound economics – and an investment in a more self-reliant, resilient health system.
Understanding why the disease is emerging so early helps clarify where the response should focus. Early-onset MASLD is best understood not as a single failing but as the cumulative effect of the nutrition transition that accompanies rapid urbanisation. Diets have shifted toward energy-dense, ultra-processed foods and sugar-sweetened beverages rich in fructose, which the liver converts into fat through de novo lipogenesis, driving inflammation and insulin resistance. Sedentary work and screen-based leisure reduce the muscle activity that would otherwise clear glucose, while disrupted sleep and circadian rhythm add a further metabolic burden. This profile produces a phenotype especially relevant to India — lean MASLD, the “metabolically obese, normal weight” pattern, in which lean disease accounts for close to 40% of chronic liver disease patients. An outwardly slim patient can carry significant liver injury that weight-based screening alone would miss.
The disease is also, by its nature, easy to overlook. The liver has no pain receptors, so injury can advance silently through a recognised sequence — simple steatosis, metabolic dysfunction-associated steatohepatitis (MASH), fibrosis and, ultimately, cirrhosis and hepatocellular carcinoma. The encouraging reality is that the early stages are substantially reversible: steatosis and even MASH can regress with timely intervention, and only a minority of patients – roughly one-fifth to one-third progress to MASH and 2–5% of those to cirrhosis – reach the irreversible end of the spectrum. The clinical opportunity lies in the years before symptoms appear.
Capturing that opportunity is a systems challenge as much as an individual one. Because MASLD is asymptomatic while it remains reversible, it is frequently diagnosed late, and case ascertainment in India is likely an undercount. The constructive response is a shift from reactive treatment to proactive case-finding among people with cardiometabolic risk factors — type 2 diabetes, abdominal obesity and dyslipidaemia — embedded in primary care, supported by screening pathways that account for lean disease, and reinforced by public awareness of the drivers upstream. None of this demands exotic technology; it requires that liver health be treated as a routine part of metabolic care.
India has both the scale and the scientific capacity to lead here – generating locally relevant evidence on how MASLD behaves in Indian patients and translating it into guidelines suited to Indian practice. Building early detection into the health system, while the disease is still reversible, is among the more achievable and high-return investments available in public health today. Ultimately, addressing MASLD in young India is about more than protecting individual livers; it is about equipping a health system to anticipate a metabolic epidemic rather than merely treat its consequences.
