New Delhi: When a person is diagnosed with Type 2 diabetes, doctors typically schedule regular checks for three parameters—blood sugar levels, kidney function, and eye health—to catch complications, such as retinopathy, a condition where high blood sugar damages the tiny blood vessels in the eye early.
Besides these three well-known complications of diabetes, a new study published this month in The Lancet Regional Health–Southeast Asia has made the case for a “fourth complication”.
The DiaFib-Liver Study, conducted across diabetes clinics in India and involving more than 9,000 patients, has now argued that the national health programme should also screen for liver fibrosis—the scarring of the liver, which, if left unchecked, could progress to serious liver disease.
Researchers have found that one in four adults with Type 2 diabetes in the study had significant liver scarring, and one in twenty already had probable cirrhosis—a stage where the liver is heavily damaged. Most alarming of all, almost none of the patients were aware of the issue.
What is liver fibrosis
The liver is the body’s largest internal organ. When it is repeatedly damaged by excess fat, high blood sugar, or alcohol, it tries to heal itself by laying down scar tissue. Over time, this scar tissue builds up, and it develops into fibrosis.
In the early stages, it causes no symptoms. However, as scarring progresses, the liver gradually loses its ability to function. When the damage becomes extensive, the condition is called cirrhosis, at which point the liver can’t repair itself. This can lead to liver failure, internal bleeding, and liver cancer.
According to the study, diabetes accelerates this process. High blood sugar, as well as insulin resistance, promotes fat accumulation in the liver, triggering chronic inflammation and driving the condition of fibrosis. Now, it is formally called ‘Metabolic dysfunction-Associated Steatotic Liver Disease (MASLD)’, though most people still know it as fatty liver disease.
“Fatty liver has become an epidemic. One of the important reasons for fatty liver is diabetes,” said Dr Ashish Kumar, Senior Consultant, Gastroenterology, Sir Ganga Ram Hospital, New Delhi, and the study’s lead author.
The study noted that people with Type 2 diabetes not only have a higher chance of developing fatty liver disease but also tend to progress faster to advanced scarring and cirrhosis. This makes liver disease a particularly serious, and often invisible, risk for hundreds of millions of people living with diabetes.
Type 2 diabetes affects over 500 million adults worldwide, and that number is expected to cross 780 million by 2045, with the steepest rise in lower-income countries.
India sits at the centre of this crisis. According to an Indian Council of Medical Research study, the country already has 101 million people with diabetes and another 136 million with prediabetes, and the total is expected to cross 150 million by mid-century.
What the study found
Dr Kumar and his colleagues invited nearly 82 to 90 diabetes specialists and endocrinologists from across India to submit data on their patients, all of whom were asymptomatic for liver disease and simply attending routine diabetes appointments.
These patients were tested using a FibroScan, which is scientifically labelled vibration-controlled transient elastography (VCTE). It is a simple, painless, ten-minute test that measures the stiffness of the liver. The stiffer the liver, the more scarring is present.
The results of the study, Dr Kumar said, were alarming. Twenty-six percent of the patients—roughly one in four—had clinically significant fibrosis. Fourteen percent had advanced fibrosis.
And, five percent—one in twenty—already had cirrhosis-level liver stiffness, despite having no symptoms.
“They had diabetes, many of them were obese, and they had silent liver disease going on in their liver, which was detected only through FibroScan,” Dr Kumar told ThePrint.
The study found that obesity nearly doubled the risk of fibrosis. Long-standing diabetes, abnormal blood fat levels (dyslipidaemia), and reduced kidney function were also independent risk factors. Strikingly, even among non-obese patients—those a doctor might consider lower risk—nearly one in five had significant fibrosis.
What’s screened & what’s missed
In February 2021, the Ministry of Health and Family Welfare integrated fatty liver disease into the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS), which was launched in 2010 to screen and manage major non-communicable diseases.
But those guidelines screen for fatty liver, not fibrosis, which represents different stages of liver disease.
“The current protocol only looks at non-alcoholic fatty liver using ultrasound and simple anthropometric measurements to identify obesity. What we are proposing is to integrate fibrosis assessment into the programme, using tools like the FIB-4 test, which can be done even at primary healthcare centres,” said Dr Kumar.
Anthropometric measurements refer to basic body metrics, such as BMI and waist circumference, used to assess obesity risk, while the FIB-4 test is a simple blood test that helps estimate liver fibrosis using routine lab values.
The study found that 13 percent of patients with no detectable fat already had significant fibrosis, whereas four percent already had probable cirrhosis. Using fat as the gateway to fibrosis screening will systematically miss this entire group entirely.
“Once liver disease progresses, it progresses to cirrhosis. The in-between stage is fibrosis. We need to screen for fibrosis before cirrhosis develops,” Dr Kumar said.
Does every diabetic need FibroScan
According to Dr Saket Kant, Senior Consultant in Endocrinology at Max Healthcare, the gap in routine care was a serious concern.
“A significant number of Type 2 diabetes patients may have underlying fatty liver or even fibrosis without obvious symptoms, which makes early detection critical,” he said.
Researchers suggest that every person with diabetes should be screened for fibrosis using either a FibroScan or a simple blood test called the FIB-4 index—a calculation using age, two routine liver enzyme levels, and platelet count. It can be done at district hospitals and primary health centres, without expensive equipment, making it viable even where FibroScan machines are unavailable.
Dr Anoop Misra, chairperson of Fortis C-DOC Hospital for Diabetes and Allied Sciences in New Delhi, and a co-author of the study, told ThePrint that while FibroScan remained the gold standard, it was simply not available at most primary health centres, and general practitioners were unlikely to order one routinely.
FIB-4, he said, was a far more realistic screening tool for the national network—and the two could work in tandem, with a high FIB-4 score triggering a follow-up FibroScan, where available.
A separate consensus guideline published last year by nine Indian medical experts, including Dr Misra and Dr Kumar, recommended mandatory fibrosis screening for all people with Type 2 diabetes. These were the first guidelines specifically tailored to managing fatty liver disease in Asian Indians with diabetes.
(Edited by Madhurita Goswami)
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