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The Dangers of Fatty liver…It may catch you unawares

Monitor News Bureau

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Dr M Shafi Kuchay

R K Gupta, a fine gentleman, is living with type 2 diabetes and hypertension since age 50. He is also known to have fatty liver, first seen on ultrasonography when he was 45 years of age.

He has been controlling his diabetes and hypertension well, following all the advices of his doctor. It is, therefore, no surprise that even after 17 years of diabetes and hypertension, he has no complications like diabetic eye disease or diabetic kidney disease.

 

Mr. Gupta will celebrate his 67th birthday in the coming week. So far, so good.
Last week, he got his routine blood testing done.

He was surprised to see that his hemoglobin and platelet counts were low. He consulted his doctor, who suggested a few other investigations including ultrasound of his abdomen. Ultrasound revealed shrunken liver.

The doctor suspected liver disease and referred him to a liver specialist. After many more investigations, he was confirmed to have cirrhosis of liver. The diagnosis was a bolt from the blue for Mr. Gupta. He was confused and stunned.

He has been controlling his diabetes and hypertension so well, he had never imagined that he would develop a disease like cirrhosis of liver. The liver specialist came to the conclusion that his long-term fatty liver had given rise to cirrhosis of liver.

R P Gupta has been having fatty liver since age 45. He was told by many, including his doctor, that it was a harmless condition. He had never bothered about his fatty liver. How could this seemingly innocuous condition would destroy his liver?

A decade ago, fatty liver was considered a benign condition. Research in recent years proved, beyond any doubt, that fatty liver can progress to a more severe condition called nonalcoholic steatohepatitis (NASH). NASH signifies that fat droplets has given rise to inflammation in the liver.

In a few individuals, NASH can, over years, progress to cirrhosis of liver. Cirrhosis means scarring of liver, which ultimately leads to liver failure.

When fat builds up in liver cells (hepatocytes), it is called fatty liver. It is a disease because a liver cell is not a store house for fat. Fat droplets build up in the liver because there is excess of fat in the body.

This occurs due to long-term over-nutrition and underactivity. In the modern era, because of always-sit-in-a-chair type lifestyle and energy-dense food environment, fatty liver disease has hit epidemic proportions. Globally, fatty liver is the most common liver disease. In the industrialized world, fatty liver disease is the number one cause for liver transplantation.

Fatty liver disease, like type 2 diabetes, is a life-style disorder. As is true with type 2 diabetes, fatty liver increases your chances of being hit by a heart attack or stroke. It also impairs your kidney functioning. But unlike type 2 diabetes, there is not a single medicine approved for treating fatty liver disease. This is because no medicine has been proven beneficial beyond doubt for this disease.

However, there are some strategies/medicines that may help to some extent. Life-style modification (diet and exercise) has been shown to reduce liver fat in a number of studies. Weight loss of more than 10 per cent is required for reducing fat and inflammation in the liver. But long-lasting lifestyle changes are not sustained for prolonged period of time. Although diet and exercise are advised to all diabetes patients, only a small proportion of patients are actually able to adhere to the advice. Having said this, you must, however, never stop following a healthy lifestyle. A good diet and regular exercise not only reduce liver fat, but also improve almost all organs and give you overall fitness.

A diabetes medicine, pioglitazone, has been shown to improve fatty liver disease. However, in the famous PIVANS study, the improvement was modest. Another reason for its lack of use in fatty liver disease is its undesirable side-effects. Pioglitazone increases body weight that most patients do not like. It also causes fluid retention that is not desired in patients with type 2 diabetes who are already at risk for heart failure. These are the reasons pioglitazone is not a favorite medicine among most experts as well as patients.
Liraglutide is a daily injectable medicine that has been approved for type 2 diabetes. This medicine reduces body weight as well. In fatty liver studies, liraglutide reduced liver fat and improved inflammation of liver. Although liraglutide improves fatty liver disease, but being an injectable and a costly drug, its patient acceptability is poor.
Gliflozins (empagliflozin, Dapagliflozin) are new anti-diabetes medicine. As this medicine causes loss of glucose through urine, its long-term use leads to chronic calorie loss and thereby weight loss. Many members of this group have been shown to reduce liver fat. In diabetes patients who also have fatty liver, these medicines can be useful. It would be like ‘one arrow two targets’ strategy.
There are many other drugs that are in pipeline for fatty liver disease. These medicines have been designed to reduce inflammation and fibrosis that fatty liver gives rise to. But, before a new medicine gets approved for fatty liver, it must pass the test of efficacy and safety.
Meanwhile, Mr. Gupta is doing well on medicines. His hemoglobin and platelets have improved a bit. He might require liver transplantation for cirrhosis of liver if he develops recurring complications. Unlike Mr. Gupta, you don’t have to wait for complications to occur. If you have fatty liver disease, talk to your doctor about it. Follow healthy dietary patterns and exercise regularly
(The author is a consultant endocrinologist and researcher working in Medanta The Medicity Hospital, Gurugram and can be reached at [email protected])


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Opinion

Pakistan’s real ideological fault line

The Kashmir Monitor

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By Yasser Latif Hamdani

In the on-going political maneuvering and power plays between various state institutions and political parties, Pakistan as a nation state has taken its eyes off the real ideological fault line in Pakistan which lies between Orthodox reactionaries and the Muslim Modernists.

NadeemFarooqParacha’s excellent study “Muslim Modernism; the case for a Naya Pakistan” succinctly summarises the history of the defeat of the idea of Muslim Modernism in Pakistan. The idea of Pakistan was a Muslim Modernist project that took root in Aligarh Muslim University, the arsenal of Muslim India. It was in the hallowed halls of that great university that the plans of a new Muslim majority nation state were debated and finalized. It had a direct link to Sir Syed Ahmad Khan’s legacy of keeping Muslims away from Congress, which he charged with being a Hindu dominated body. Men like Jinnah who had joined the Congress and the mainstream of the Indian Nationalist struggle ultimately were forced to accept the wisdom of the grand old man of Aligarh. By the 1940s, the Best Ambassador of Hindu Muslim Unity had taken on the role of the undisputed Quaid-e-Azam of Muslim India and the movement he spearheaded was the apex of Muslim modernism. Arrayed against him were reactionaries of Majlis-e-Ahrar and Jamiat-e-Ulema Hind backed by the Indian National Congress. They attacked and abused him for being too modern and too secular. Their real ire was against the very idea of Muslim modernism that Jinnah had come to embody.

 

Muslim modernism in South Asia was an idea that was born out of the fall of the Mughal Empire. It stood in stark contrast to the other modern Muslim ideas including Islamic fundamentalism. Islamic fundamentalism called for a return to what they viewed as fundamentals of Islam and was inherently sectarian in nature. Muslim modernism rejected the idea of a fixed dogma and instead emphasized the dynamic and ever evolving nature of Islam through the principle of Ijtehad. Muslim modernism also embraced modern education, secular system of government and modern economy. Syed Ameer Ali’s classics “History of Saracens” and the “Spirit of Islam” were written in this vein. Iqbal was another figure in this movement towards modernity who with his “Reconstruction of Religious Thought in Islam” laid out a roadmap with identifiable waypoints on the route to Muslim enlightenment and renaissance through an embrace of modern knowledge and modernity. To achieve this, Muslims of the subcontinent needed a state of their own, within or without the Indian whole. This in a nutshell was the idea of Pakistan.

When the idea of Pakistan began to take root amongst the Muslims, leaders of religious orthodoxy calculated that if these men managed to seize the leadership of the Muslim community, the ulema would be left out in the cold. Therefore the Jamiat-e-Ulema Hind and Majlis-e-Ahrar, which were led by men seized of an irrational hatred for all things modern and by extension western and British, put in their lot with an increasingly nativist Indian National Congress under Gandhi. After all Gandhi, who had shunned western modernity, had supported them during the Khilafat Movement. The calculation was that in an India dominated by the Hindu majority, the Muslim community will forever be in the sway of the bearded men with flowing robes educated at Darul-UloomDeoband. With the help of their Hindu friends, the leaders of this religious reaction set up a university of its own in form of Jamia Milli. They set about trying to divide the ranks of the Muslim League by raising sectarian questions against Shias and Ahmadis, many of whom were in leading positions in the League.

Pakistan from 1947 to 1977 was committed to the idea of Muslim modernism. While some tragic compromises were made on the way in the closing stages of the Ayub regime and by Zulfikar Ali Bhutto, the state was moving in the general direction of becoming a modern democratic state based on principles of enlightenment. General Zia ulHaq changed all of that. A massive re-writing of the history of the Pakistan Movement was undertaken and Muslim modernism was slowly but surely written out of it. This was done under the auspices of parties like Jamaat e Islami whose historical role against the Pakistan Movement was conveniently ignored and who began a massive re-engineering project to make Pakistan a fundamentalist state. The generation that grew up in the 1980s and 1990s grew up with a world view that rejected modernity. It was in large part aided by Pakistani diaspora who had arrived in the Gulf in the 1970s. Islam was equated with all things Arab. It was a striking departure from Iqbal’s famous Allahabad address where he had put as one of the objectives the idea of liberating South Asian Islam from the stamp of Arab imperialism. Thus from 1980s Pakistan had not just rejected Jinnah’s secularism but also comprehensively buried the very idea which had led to its creation. Jinnah’s ideas had already been marginalized but now Iqbal was sanitized and only those parts of his philosophy were allowed dissemination that fit the regime’s Islamisation.

This is what makes the ongoing political battles entirely out of step with the real ideological issue in Pakistan. The current government’s overbearing attitude towards freedom of speech masks the low-grade conflict between the modernists and the orthodoxy. What is at stake is our future as a people and our attitudes to new problems that face us. Ultimately the direction human progress takes is one and that is forward. Gender rights, freedom of speech and even questions of sexuality will become major points of contention in very near future. Will we then remain wedded to an orthodox fundamentalist interpretation of our faith or will we embrace the idea of modernity itself marching in step with the rest of the world. None of our politicians or other power brokers seem to realize the challenges ahead. As a first step though we must reject the faux national narrative that has been shoved down our throats since the 1980s and re-invigorate the inherently enlightened and modern ethos that led to the formation of Pakistan.

(The writer is an Advocate of the High Courts of Pakistan and a member of the Honourable Society of Lincoln’s Inn in London. This article first appeared in Daily Times, Lahore)

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Opinion

Beyond winning and losing

The Kashmir Monitor

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By Jawed Naqvi

Seeing the legendary Farokh Engineer among the spectators at the Old Trafford, with his shock of curly white hair and a Falstaffian girth that seemed to meld nicely with his incorrigibly impish smile, my mind went into the enticing time machine for a rendezvous with the great Parsi cricketers India once flaunted.

Then, the penny dropped.

 

The 1983 and 2011 Indian cricket teams that won the world cup encompassed what Rahul Dravid would call the country’s cultural colours, which were just about missing in ViratKohli’s social mix. This is not to say that a cultural mix is necessarily more formidable or that it would have produced a happier result, say, in the critical semi-finals that India lost to New Zealand. In fact, on the flip side of the argument, the all-white South Africans were probably the stronger team in the world on their day, even if few were willing to court them for fear of violating stringent anti-apartheid laws.

The all-black West Indies could be just as invincible on a given outing, but they gained and certainly didn’t lose when RohanKanhai and Alvin Kalicharan came into the squad with a different colour of skin, just as MakhayaNtini, HashimAmla or Imran Tahir among others brought new energy to the post-apartheid South African team.
And why forget that even the West Indies inducted a white player in the squad against New Zealand in the 1970s.

And doesn’t it behove mention that the solitary black man in the squad who delivered the crushing blow for the mainly white English team in the nail-biting finals against New Zealand at Lord’s was not even in the national eleven a few weeks earlier?

In the early days of Indian Test cricket, it was a common habit to expect Parsi players of the order of Nari Contractor, Polly Umrigar, Engineer or RusiSurti to embellish every Indian’s favourite team. It was thus that for a predominantly Hindu country, KapilDev’s squad that lifted the first World Cup for India boasted of Roger Binny, Syed Kirmani and Balwinder Singh Sandhu who added to the cherished moment on the world stage, just as Harbhajan Singh, Sreesanth, Zaheer Khan, Yusuf Pathan and Munaf Patel were in the trophy-winning squad in 2011.

One could identify at least two solid players in the Bangladesh World Cup squad who breached its dominant cultural profile. And in a heavily Sinhalese Sri Lanka, where would the team stand without the priceless talent of MuttiahMuralitharan?

Pakistan, where display of majoritarian religion has gained currency for a variety of sociopolitical reasons, Anil Dalpat and Yusuf Youhana had fortified the squad. It is another matter that Youhana discovered greater spiritual solace in embracing the identity of Pakistan’s religious majority.

A country’s approach to inclusivity need not, of course, be worn as a cultural amulet in a thread around the neck. New Zealanders, for example, found a subtler method to express their eclectic cultural expanse — by singing the national anthem in two languages, English and Maori, spoken by the country’s original inhabitants.

We had read in school about Britain’s bold, risky, but often humorous enterprise to initiate the natives of Gilbert and Ellis Islands to cricket. A Pattern of Islands by Sir Arthur Grimble was a regaling story as much as it also informed the reader about the colonial celebration of cultural diversities they tried to encourage and preserve, including by introducing cricket to the remote Pacific islands.

A friend recently forwarded an essay from the BBC’s website by PrashantKidambi of Leicester University. It offers a brilliant insight into the early efforts of Indian and British elite to stitch together an ‘Indian’ cricket team.

“In this last decade,” Kidambi quotes former cricketer Rahul Dravid as saying in 2011, “the Indian team represents, more than ever before, the country we come from — of people from vastly different cultures, who speak different languages, follow different religions, belong to different classes.”

And yet, the link between cricket and the nation was neither natural nor inevitable.

“It took 12 years and three aborted attempts before the first composite Indian team took to the cricket field in the summer of 1911. And contrary to popular perception — fostered by the hugely successful Hindi film Lagaan — this ‘national team’ was constituted by — and not against — empire.”

The first Indian cricket team sparked great interest in the British press, according to the historian from Leicester. A diverse coalition of Indian elite and British governors (among others) made possible the idea of Indians on the cricket pitch.

The ‘Indian’ cricket team was thus first broached in 1898, inspired by the rise of Kumar ShriRanjitsinhji, or Ranji, an Indian prince who bewitched Britain and the wider imperial world with his sublime batting.

The early British ventures failed to put together a team “because of fierce divisions between Hindus, Parsis and Muslims over the question of their representation in the proposed team”.

When they succeeded, the captain of the team was 19-year-old Bhupinder Singh of Patiala, “the pleasure-seeking, newly enthroned maharaja of the most powerful Sikh state in India”.

Others were selected on the basis of religion: there were six Parsis, five Hindus and three Muslims in the side. PalwankarBaloo, the Dalit bowler, was the “first great Indian cricketer”, Kidambi writes.

“The composition of this team shows how in the early 20th-century, cricket took on a range of cultural and political meanings within colonial India.”

Farokh Engineer’s presence in Manchester reminded me of a hair cream the debonair cricketer advertised — and a generation embraced. But he also triggered memories of an interview the great playback singer AshaBhosle gave. Asked to choose between Kishore Kumar, Mukesh and Manna Dey as her favourite legendary duet singers, she said: “You have forgotten Mohammed Rafi.”

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Opinion

NRC: A major storm is brewing

The Kashmir Monitor

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By Sanjoy Hazarika

The National Register of Citizens process in Assam ploughs relentlessly on. At the end of this month a full list is to be published, ostensibly of all Indians identified in the state. That is when the scale of misery and jubilation may be gauged. Yet that’s not the end of this long, complex journey.

A few days back, another list was published of one lakh persons who are to be left out of the list because they could not produce convincing documentation; this followed scattershot complaints by unidentified persons against some who were already on the NRC.

 

For those who do not make the cut on July 31, there is a longer battle in store — they will have to spend time, funds (invest in lawyers) and appear before quasi-judicial processes, the foreigners tribunals, to prove their nationality. These courts, manned by lawyers without extensive judicial experience or deep knowledge of jurisprudence, are the first point of appeal followed by the state high court and finally the Supreme Court.

The Assam government had said it would add 400 FTs more to the current 100 (it later promised 1,000), but has it made the clear determination of whether the person is fully qualified for that office and can take a decision without fear or favour?

Many of us who have followed the long and tortuous journey of the NRC — and the earlier struggle between the 1970s-1980s by student groups and others for detection of foreign nationals (that is, the ubiquitous ‘Bangladeshi’) — had pinned faith in a process that would create a list which would be clean, clear and correct. Knowing the complexities of Assam, a simple land with deep divisions, this was perhaps a naive hope.

The ‘foreigners issue’, as the question of informal migration (largely from Bangladesh) is defined in popular terms in Assam, is a challenge that goes back to the time of Independence. However, critical perceptions about in-migration and demographic change precede that.

Assam now appears to be entering an uncertain period with little clarity on a fundamental question: will the list competently identify ‘foreigners’? Arguably some 29 million persons had made the cut last July but all hell broke loose with the announcement that nearly four million had not. Of the latter, 3.2 million persons have petitioned for their inclusion and the issue has figured at international and national forums. Some of the stories which have emerged over the past year are worth repeating, for they cut across religious, ethnic and language divisions and point to major inaccuracies.

In case after case, a pattern has emerged showing a combination of poor judgment, problematic data, arbitrariness or just indifference that has harmed Indians. A Kargil veteran who was marched into a detention camp and then released; a policeman who cannot vote since he has been proclaimed a foreigner; a 92-year-old man who has had to be carried into court to face trial; a woman who ended up in a detention camp when the police could not find the person they were looking for and just picked her up; prominent Gorkhas including a SahityaAkademi winner find themselves in the excluded list. In many cases, a mismatch of a letter in a name connecting them to either parent or grandparent was enough to bar them.

Most of the cases cited above, barring the Gorkhas, were people of Bengali origin, both Hindu and Muslim. It is not just about religion. The poor and vulnerable who cannot afford lawyers find themselves in this situation.

The NRC impact is spreading: other states are arming themselves with similar plans. Nagaland has started a 60-day exercise aimed at identifying the indigenous people (read members of 16 Naga tribes whose homes are in the state) and one anti-immigrant group has declared that the “indigenous” are those who are “Naga by blood”. Does the definition of the indigenous in Nagaland includes mainland Indians, be they Assamese, Bengali (Hindus and Muslim), Marwari, Bihari or from other parts of this country?

It does not take a tarot card reader to see that a major storm is brewing. Many may not have predicted this when the NRC was given wings in 2016, after the BharatiyaJanata Party gained power in Assam. What has unfortunately happened is that the exercise in Nagaland and in parts of Assam could end up condemning Indians to an appalling fate.

Even pro-BJP groups recognize this. One said recently that it had procured 2.8 million signatures of people in Assam demanding an “error-free NRC”. It pointed out that the Supreme Court itself had suggested a pilot sample reverification of 10 per cent of the total number on the NRC but not issued orders for this. Its concern was that many Hindus of Bangla origin would be left out.

A recent citizen’s group which travelled across three districts in Assam found that many women, both Hindu and Muslim, have been declared foreigners because they did not have the documents to link them to their father, the crucial “legacy data” or family tree link in the NRC.

PrateekHajela, the NRC state coordinator, has said that “inability to provide linkage documents appears to be the biggest reason why applicants couldn’t substantiate their claims”.

Indeed, from its very start, the NRC exercise has struggled with technical hurdles.

For one, the key base document for the NRC is its predecessor: the first and only NRC of 1951. Yet enumerators found that copies of this NRC were not available in three districts: Sivasagar, Cachar and KarbiAnglong. So new data based on 16 parameters were developed for these district populations — 67 to 68 years after this initial exercise, based on electoral rolls and census data. Two separate systems of checks and cross checks have had to be created, quite different from each other. Is it surprising that there should be confusion?

The exercise is officially over on July 31. But there is no clarity on what happens to those out of the lists — will they stay at their homes and fight trials, will they have to move elsewhere, will those found as foreigners by FTs be sent to detention camps after a 120-period when appeals can be heard?

A Union minister of state for home affairs has told Parliament that a new manual for detention camps was being prepared with the following proposed facilities: “electricity, drinking water, hygiene, accommodation with beds, sufficient toilets with running water, communication facilities, provision for kitchen”. The draft manual has been sent to all state governments raising questions about how long the Centre proposes to keep people at such sites.

This is aimed obviously at blunting criticism by some who have been released from detention camps in Assam after their Indian-ness was upheld. They describe conditions are appalling with scores packed into a single room and sharing a single toilet.

Exacerbating the issue is the fact that even those detected as Bangladeshis cannot be deported unless Bangladesh acknowledges them as its own — which it steadfastly refuses to do.

Governments are required to uphold Constitutional obligations, especially Article 21 of the Constitution, which proclaims that no one may be deprived of his life and liberty except by due process. In addition, there are India’s international commitments to the Universal Declaration of Human Rights which does not recognize statelessness.

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